This special focus chapter provides an overview of policies for stockpiling medical goods as a first short-term buffer layer for pandemic preparedness and response. It draws on insights from several OECD countries and the European Union, describing some of the practical considerations, implications and challenges of strategic and co‑ordinated stockpiling.
The Economic Case for Pandemic Preparedness and Response
Beyond Lockdowns
Abstract
Key messages
Stockpiling of relevant medical goods, such as medical countermeasures, is important for timely and effective pandemic preparedness and response capacity
Strategic stockpiling is the proactive accumulation and maintenance of a critical supply of relevant medical goods, such as medical countermeasures used to diagnose, prevent, protect from, or treat conditions during a public health emergency. The rapid deployment of these supplies serves as an important first-layer response during the initial stages of a public health emergency and forms an important part of pandemic preparedness and response. In preparation for severe crises, stockpiling offers a short-term solution while manufacturing and production capacity of relevant goods are ramped up.
During COVID‑19, sudden large increases in demand, coupled with supply disruptions due to imposed restrictions and supply chain bottlenecks saw critical shortages in basic supplies of personal protective equipment (PPE) and essential medicines such as anaesthetics.
Stockpiling systems have variable scope, objectives, governance, and financing arrangements
National and regional stockpiling strategies have differing and multiple objectives, including various types of products for different crisis events, such as pandemics, natural disasters, chemical, biological, radiological and nuclear (CBRN) threats, and the threat of antimicrobial resistance.
Prior to the COVID‑19 pandemic, 16 of 23 surveyed OECD countries stated in 2022 that their preparedness plans included provisions for stockpiles of vaccines and medicines, and 11 of 23 countries included provisions for PPE procurement and logistics.
Effective stockpiling policies require strategic planning and risk assessment, clear governance structures, sustainable funding and reimbursement arrangements, as well as effective inventory management and logistics. The responsibility of national physical emergency stockpiles often lies with government authorities (e.g. in Canada, France and the United States), although there are some cases where companies may also be under obligation to increase their own inventories to a defined level with or without compensation.
Regional EU stockpiles are an example of co‑ordinated strategic stockpiling
One challenge with national stockpiling policies is that accumulating larger quantities of essential medical supplies at national or subnational levels may lead to unintended consequences, such as shortages for regular use, price increases, and wastage of unused stock.
Regional stockpiling and pooled procurement can be considered a pragmatic option in some circumstances for certain goods, provided that allocation of products during times of crises are well defined. Under the EU Civil Protection Mechanism’s rescEU initiative, the European Commission established a regional strategic stockpiling mechanism in 2020 aimed at preparing and responding to health crises and large‑scale disasters. Here, 22 stockpiles are strategically hosted across 16 EU Member States, with stock covering three priority threats (pathogens of pandemic potential, antimicrobial resistance and CBRN) and to be used as a last-resort option. Building on the lessons from rescEU, the 2025 EU Strategic Plan for Stockpiling Medical Countermeasures aims to enhance preparedness and response for priority threats through efficient, effective EU-level stockpiling that complements national and global initiatives in a cost-effective manner.
Designing stockpiling policies should consider several challenges
Assessing the costs and benefits of stockpiling policies is challenging as evidence on costs and cost-effectiveness of stockpiling are sparse. Nevertheless, previous evidence points to the importance of considering the financial sustainability of the stockpile, the high uncertainty and predictability in the virulence and infectiousness of future pathogens of pandemic potential, the value of robust logistics and inventory management systems for stock management, and effective co‑ordination, communication and information-sharing among relevant stakeholders (e.g. national and local authorities, healthcare providers, industry partners, the public).
Finally, it should be recognised that while stockpiling is an immediate response capacity that provides only a finite supply and offers limited effectiveness during prolonged disruptions. Ensuring ongoing supply of critical goods to populations goes beyond stockpiling initiatives.
Strategic stockpiling is the proactive accumulation and maintenance of a critical supply of relevant goods, such as medical countermeasures (MCMs),1 the rapid deployment of which serves as a first buffer layer in public health emergencies by providing critical supplies during the initial stages when market supply may be unable to meet high demand (OECD, 2023[1]; OECD, 2024[2]). As was the case with the COVID‑19 pandemic, the onset of a large‑scale event can result in shortages of basic supplies of PPE, including face masks, gowns, and gloves, as well as essential medicines such as anaesthetics. These shortages are amplified by sudden large increases in demand coupled with disruptions in supply, for example due to imposed restrictions and supply chain bottlenecks. Companies generally manage seasonal or unexpected volatility in demand on a small or medium scale to ensure reliable supply of their product. However, in preparation for an event such as a pandemic, national or regional stockpiling of basic critical supplies and essential medicines may be needed to offer a short-term solution while manufacturing and production capacity is ramped up to meet unprecedented demand.
A recent OECD report, Securing Medical Supply Chains in a Post-Pandemic World, identified appropriate inventory strategies and co‑ordinated strategic stockpiling as part of the basket of policy measures to enhance the resilience of medical supply chains, both under routine circumstances as well as in preparation for a severe crisis (OECD, 2024[2]). However, it also recognised that some stockpiling techniques could have a negative impact on supply. For example, increasing volumes of (national or local) stockholdings of supplies, particularly amid a crisis, can lead to counteractive outcomes, such as causing product shortages elsewhere, driving up prices, or resulting in wastage from unused stock. This report further underlined that stockpiling cannot serve as a long-term solution for strengthening the resilience of supply chains more broadly, as it provides only a finite supply and offers limited effectiveness during prolonged disruptions (OECD, 2024[2]).
Building on insights from the recent OECD report (2024[2]), as well as those found in the literature, this special focus chapter aims to focus on practical implications of stockpiling specifically for pandemic preparedness and response. This is challenging, however, as national and regional stockpiling strategies often have differing and multiple objectives and include various types of products for different crisis events, and not only limited to medical products like PPE and medicines, but also other inventory including back-up personnel and hospital beds. The analysis is also limited by a lack of transparency regarding stockpiling strategies, which may be due to national security reasons, risk of market disruptions etc. Consequently, to the extent possible, the current analysis benefits from understanding stockpiles developed for various purposes, though it is not exhaustive. The special focus chapter is organised as follows: Section 9.2 describes the context of medical supply chains and why strategic stockpiling might be necessary as a first-layer buffer for pandemic preparedness and response. Sections 9.3 and 9.4 describe some examples of different stockpiling policies implemented by countries and in the European Union (EU), respectively. Section 9.5 discusses some of the limitations of stockpiling and practical implementation issues. Annex 9.A contains an overview of some specific stockpiling initiatives.
In today’s interconnected world, governments need to be ready to address potential supply chain disruptions in preparation for public health emergencies. As seen with COVID‑19, lockdowns, travel bans or restrictions imposed during pandemics have resulted in disruptions to transport, freight, logistics and customs activities, adversely affecting the movement of goods across borders (OECD, 2024[2]). This is pertinent to medicines and medical devices, as their production from raw materials, intermediate inputs, or components to finished products involves complex, increasingly transnational, supply chains, with multiple stakeholders across different facilities and countries.
As described in the recent OECD medical supply chain report, over the last 30 years, global trade in pharmaceuticals has increased 10‑fold, amounting to USD 900 billion in 2022, half of which is attributed to intermediate inputs such as active pharmaceutical ingredients (OECD, 2024[2]). Over the same period, global trade in medical devices has increased seven‑fold, reaching USD 700 billion in 2022. More than a third of trade in medical devices by value is attributed to medical equipment (34%), followed by PPE (30%) and other medical supplies (25%). In Europe, parallel trade also allows the free movement of goods within the European Economic Area (ibid.). While trade is important to ensure the continuity of supply chains and has played an important role to address pandemic-related disruptions and shortages, strategic stockpiling policies are used by countries as interim buffer solutions to allow for rapid deployment of medical goods during the initial stages of a large‑scale emergency event (OECD, 2024[2]).
Stockpiling has been widely recognised as a risk management strategy for national response efforts to public health emergencies. Prior to the COVID‑19 pandemic, 16 of 23 countries that responded to the OECD Resilience of Health Systems Questionnaire 2022 stated that their preparedness plans included provisions for stockpiles of vaccines and medicines, and 11 of 23 countries included provisions for PPE procurement and logistics (Figure 4.1, (OECD, 2023[1])).
In its 2021 guidance, the World Health Organization (WHO) identified strategic health stockpiles as one of the resources that countries may deploy as part of their national response to a variety of health emergencies and disasters (WHO, 2021[3]). For example, the WHO also defined a list of products specific to radiological and nuclear emergencies that it recommends for national stockpiling (WHO, 2023[4]). However, the WHO Pandemic Agreement formally adopted on 20 May 2025 calls on countries to “avoid maintaining national stockpiles of pandemic-related health products that unnecessarily exceeds the quantities anticipated to be needed for domestic preparedness and response” during a pandemic emergency (WHO, 2025[5]).
At the EU level, the European Commission’s Health Emergency and Response Authority (HERA) was created in 2021 to better prepare for and respond to cross-border threats, including 1) pathogens with high pandemic potential, 2) chemical, biological, radiological and nuclear (CBRN) threats, and 3) threats from antimicrobial resistance (EC, 2021[6]; EC, 2022[7]). HERA’s mandate includes enhancing MCM stockpiling capacity at EU level to secure ready availability and accessibility of MCMs and also recommends the creation and management of national stockpiling strategies (HERA, 2023[8]).
The sections below describe some of the practical considerations for stockpiling of medical goods or countermeasures, which covers strategic planning and risk assessment, governance model and management, funding and reimbursement arrangements, and inventory management and logistics (Figure 9.1. ). This is not intended to be exhaustive but draws on lessons learned from several country experiences.
As previously highlighted in the OECD report (2024[2]), OECD countries have implemented national stockpiling systems with variable scope, objectives, governance, and financing arrangements (see Annex Table 9.A.1. , Annex 9.A, for some examples in Australia, Canada, Colombia, Korea, Spain, Switzerland and the United States). Among others, the current analysis draws on insights gained from a recent report by the Health Information and Quality Authority (HIQA), an independent statutory authority in Ireland, which overviewed national MCM stockpiling in five countries (France, Latvia, Lithuania, the Netherlands, and Norway), based on expert interviews, to inform the development of a national MCM stockpiling strategy for Ireland (HIQA, 2023[9]). A HERA commissioned report on the feasibility of stockpiling against antimicrobial resistance (AMR) threats in EU countries also informed the analysis (European Commission, 2022[10]). Box 9.1 describes the specific situation in the United States, with further information on some countries available in Annex 9.A.
Note: AMR: antimicrobial resistance. CRBN: chemical, biological, radiological, nuclear. PPE: personal protective equipment. This list is not intended to be exhaustive.
The U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response oversees the United States’ Strategic National Stockpile (SNS) (ASPR, n.d.[11]). The federally-managed SNS contains large quantities of medicines and other medical supplies to be deployed to States and local health jurisdictions as a last resort to respond to a public health emergency, including bioterrorist attack, outbreak, earthquake etc, or any severe event in which local supplies are insufficient for the response (Congressional Research Service, 2023[12]). More than 250 civil servants, the U.S. Public Health Service officers, and contractors are organised to support the SNS – staff include those with backgrounds in pharmacy, clinical care, emergency management, medical logistics and operations, quality control, public health, procurement, financial management, information technology, strategic planning, training, policy and communications (ASPR, n.d.[11]). Each State has plans for rapid distribution of the SNS.
The contents of the stockpile are not public but generally include a broad range of medications such as antibiotics, antidotes and antitoxins, as well as vaccines and other biological products, medical devices such as ventilators and other equipment and ancillary supplies including PPE and surgical items (ASPR, n.d.[11]; Congressional Research Service, 2023[12]). The SNS also includes pre‑determined deployable packages such as CHEMPACKs1, Federal Medical Stations 2, and other combination packs that contain pre‑identified supplies to address specific needs such as Push-Packages3. The types and quantities of stockpiled products are determined by the Department of Health and Human Services Secretary who, with the assistance of an interagency group, reviews the stockpile annually to ensure that contents are consistent with current health threats (Congressional Research Service, 2023[12]).
The annual allocation of federal funds to the SNS pre‑COVID was USD 610 million in 2019, increasing to USD 705 million in 2020 and 2021, USD 845 million in 2022, and USD 965 million in 2023, 2024 and 2025 (HHS, 2021[13]; HHS, 2022[14]; HHS, 2023[15]; HHS, 2024[16]; HHS, 2025[17]). Over the COVID‑19 period, the budget prioritised targeted investments in critical medical supplies as well as the development and sustainment of capabilities to prepare for and respond to pandemics, and to support expanded storage and distribution needs in light of COVID‑19 (HHS, 2022[14]). According to the budget request in 2025, of a total USD 965 million funds allocated to the SNS, around USD 791 million is projected to be allocated to products, including around USD 564 million for procurement of additional quantities and replenishment, around USD 227 million for sustainment (i.e. storage, transportation, maintenance and disposal), and USD 157 million for warehousing costs. The remaining allocation of around USD 174 million is to be allocated to SNS operational costs (e.g. costs to develop and provide guidance, training, security and other resources) (HHS, 2025[17]).
More recently, the SNS received supplemental funding to expand its pandemic preparedness portfolio, with the value of SNS inventory on medical countermeasures growing by more than 50% to around USD 13 billion in 2024, up from USD 8 billion in 2019. In the same period, the inventory volume increased by more than 400% (HHS, 2021[13]; HHS, 2024[16]). By 15 December 2022, the SNS had obligated more than USD 11 billion in supplemental funds for the COVID‑19 response, put towards increasing SNS inventories of essential medical supplies (e.g. ventilators, PPE, and pharmaceuticals), supporting COVID‑19 vaccination, boosting domestic manufacturing, transporting materials and modernising its operations (HHS, 2025[17]). Of USD 6.1 billion in COVID‑19 relief funds in 2020 and 2021, USD 3 billion went to purchasing ventilators, USD 2.4 billion to PPE, USD 494 million to vaccination supplies, USD 149 million to medications, and USD 25 million to other products (US Government Accountability Office, 2022[18]). As a comparison, nearly USD 5 billion in non-COVID‑19 funds in the fiscal years 2015-2021 were committed to buying medical countermeasures for the SNS, with approximately 75% directed towards smallpox (USD 1.1 billion) and anthrax (USD 2.3 billion) and the rest to viral haemorrhagic fever (USD 477 million), pandemic influenza (USD 191 million), ancillary and intravenous supplies (USD 124 million) and other threats such as CBRN (USD 403 million) (Congressional Research Service, 2023[12]; US Government Accountability Office, 2022[18]).
Most supplies in the SNS are in physical warehouse facilities strategically distributed across the country. For example, Push Packages3, which make up around 5% of SNS inventory, can be deployed anywhere within the country from physical stockpiles within 12 hours. Vendor-managed stockpiles are also used for around 10% of current SNS contracts. Here, the SNS pays the vendor to store and manage defined quantities of a product for SNS deployment. This type of stockpile allows the vendor to rotate product to the commercial market and the SNS and government does not need to pay for replacement of expired stock. However, delivery time from these systems usually takes around 24 to 36 hours and this arrangement is only suitable for products in which the commercial market is viable enough to sell expiring products. The SNS also uses user-managed stockpiles, whereby products for emergency scenarios (e.g. chemical warfare and antidotes) are stored at selected local medical, emergency management and public health facilities across the country for quick deployment (i.e. less than 12 hours) (Congressional Research Service, 2023[12]). The SNS maintains contracts with commercial transportation partners who can meet the most challenging delivery timelines. Effectiveness of transportation capabilities are also tested through live, no-notice deployment drills (HHS, 2022[14]).
The Inventory Management and Tracking System (ITMAS), which was released in September 2011 following lessons learned during the 2009 H1N1 influenza pandemic, helps state and local responders to manage inventory they receive from the SNS stockpile (Congressional Research Service, 2023[12]; ASPR, n.d.[19]). It allows tracking of inventory to local levels, monitoring of re‑order thresholds and supports warehouse operations (ASPR, n.d.[19]). For example, The Countermeasure Inventory Tracking Dashboard allows a graphical visualisation of the supply chains and key information on countermeasure availability (Congressional Research Service, 2023[12]). The SNS provides the Inventory Management and Tracking System and appropriate training to authorised jurisdictions at no cost.
Sustaining the stockpile requires management of the lifecycle of stockpiled products, including stock rotation to avoid expiry, quality assurance and inspections. To support with this, the Shelf-Life Extension Program applies to federal stockpiles and allows the extension of expiration dates for certain products (e.g. some medicines, vaccines and other medical products). Here, the U.S. Food and Drug Administration agency conducts periodic stability testing and the programme can extend expiry dates up to around 12 to 24 months beyond their original expiries (ASPR, n.d.[20]). Stability testing refers to assessing whether properly stored products retain their stability beyond their labelled expiration date (i.e. assessing degradation of the active ingredients, integrity of product appearance etc). Current testing in the SNS prioritises medications procured in large quantities (e.g. doxycycline, ciprofloxacin), and products with limited commercial demand (e.g. nerve agent antidotes such as atropine and diazepam), among others (FDA, 2024[21]).
Since the establishment of the SNS, the stockpile has been deployed in a variety of emergency situations including the 2011 11 September and anthrax attacks, H1N1 influenza pandemic, Ebola outbreak, Zika virus crisis, various hurricane and flooding response, and the COVID‑19 crisis (Congressional Research Service, 2023[12]). As part of the COVID‑19 response, the SNS distributed PPE (including N95 respirators, surgical and face masks, face shields, gloves, and disposable gowns) across all 50 states, the country’s four largest cities, as well as eight U.S. territories and islands. The distribution strategy was based on a pro rata allocation proportion to the population size of each jurisdiction (HHS, 2022[14]; HHS, 2023[15]). Over the more than 3‑year COVID‑19 response period, the SNS distributed 25 000 ventilators to areas in need and all 32 of the SNS’s Federal Medical Stations (ASPR, n.d.[11]; HHS, 2022[14]), 5 000 high-flow nasal cannula for respiratory support and ancillary kits that supported upwards of 1.3 billion COVID‑19 vaccinations (HHS, 2025[17]). By 18 March 2021 alone, the SNS COVID‑19 support included engagement with over 180 private industry partners for medical supply chain and delivery, more than 4 380 trucks and transporting supplies, more than 640 flights, more than 16 800 tons of cargo shipped, and with more than 200 staff working on the response (HHS, 2022[14]).
The COVID‑19 pandemic did, however, reveal vulnerabilities in global supply chains and the SNS faced several challenges early on. For example, the SNS did not hold sufficient PPE to meet demand, and the storage and distribution needs were expanded and modified in light of COVID‑19 using supplemental funds appropriated by Congress. Efforts were put in place to build the SNS’s inventory of PPE and ventilators to ensure that the SNS could meet 90 days of need for pandemic response, with progress towards meeting these goals up until December 2022 shown in Table 9.1. These goals remain lower than previous estimates of what might be needed to protect healthcare personnel in the event of a severe influenza pandemic – for example, stockpiles of 3.5 billion N95 respirators and 500 million surgical masks at federal level, and additional stock at state and local levels (Mehrotra, Malani and Yadav, 2020[22]; Carias et al., 2015[23]). The SNS greatly expanded its PPE and ventilator stockpile using temporary COVID‑19 funds, but after the Fiscal Responsibility Act of 2023 rescinded remaining balances and those funds were exhausted, it will lose this capacity as existing supplies expire (HHS, 2025[17]). The main text outlines some additional challenges faced by the SNS stockpile during COVID‑19, such as management and co‑ordination issues, areas that have subsequently been strengthened.
Note: (+) stockpiling goal met; (↑) stockpiling goal not met, but holdings have been increased from pre‑pandemic; (–) stockpiling goal not met.
1. Some PPE from the COVID‑19 response is expiring so the table shows the upper limit of what is available to use as of 15 December 2022.
Source: Adapted from sources as cited in row two of the table.
1. CHEMPACKs are containers of nerve agent antidotes placed in around 1 330 locations across the country, generally in hospitals or fire stations; most of the population is within 1 hour distance of a CHEMPACK location.
2. Federal Medical Stations (FMS) allow first responders to rapidly set up temporary medical shelters that can each treat 50‑250 patients, and contain a 3‑day supply of pharmaceuticals, medical equipment and other supplies.
3. “Push packages” are read-made containers with supplies covering a range of public health emergencies (including antibiotics, intravenous fluids, bandages, and other medical supplies).
Source: As cited. Further details on ASPR budget and funding for recent fiscal years can be found at https://aspr.hhs.gov/AboutASPR/BudgetandFunding/Pages/default.aspx, last accessed 06 November 2025. Some years have been archived but are still accessible.
9.3.1. Strategic planning and risk assessment
One of the main challenges with stockpiling is deciding what to stockpile and in what quantities to prepare for what types of crises. Emergencies that are stockpiled against include pandemics, natural disasters, as well as CBRN threats. Generally, national stockpiles include products such as medicines (including intravenous antibiotics, antivirals), vaccines, PPE, and medical devices, among other medical countermeasures against CBRN threats. Stockpiles vary in size, for example from six week to six‑month supply, and stock must be actively rotated to ensure it can be used before expiry. Stockpiles can also vary in location (e.g. held centrally, locally, in multiple locations etc), reflecting concerns around security of supply, ability to deploy quickly, and potential for wide geographic coverage. HIQA reports that while France, Latvia, Lithuania, the Netherlands and Norway all had pre‑existing MCM stockpiles, they made significant adjustments post-COVID‑19, such as adding general medicines and PPE and a review of sources of medical countermeasures (HIQA, 2023[9]). All these countries reported relying on risk assessments or various forms of analysis to identify risks that justify stockpiling. They sought guidance from expert groups to pinpoint threats, evaluate risks and determine which products to include in what quantities (HIQA, 2023[9]). A recommendation from HIQA’s review suggested that future stockpiling approaches should involve a national independent expert group or a national security board to assess risks and make decisions about what items to stockpile (HIQA, 2023[9]).
Strategic planning and risk assessment shape how countries determine what to stockpile. In Australia, the key decision-making committee for health emergencies advises on managing the stockpile (Australian Department of Health and Aged Care, 2023[24]), while in the United States an interagency group helps determine stockpiled contents, which get reviewed annually (see Box 9.1 for more details on the U.S. stockpiling system). In Korea, the Ministry of Food and Drug Safety develops a list of essential products which must be stockpiled, and other stockpiled products are informed by priority diseases identified by Korea’s Centers for Disease Control and Prevention (Ministry of Food and Drug Safety, 2019[25]). Several countries and regional authorities are also identifying “critical” medical products towards which to best direct their supply chain resilience efforts; in some cases these lists may be used to guide stockpiling (OECD, 2024[2]).
9.3.2. Governance model and management
Stockpiling strategies require a defined governance structure to ensure effective management and oversight. Common elements may include centralised decision-making bodies, collaboration between various government agencies and clear regulatory frameworks. A recent HERA-commissioned report mapping organisations and structures involved in preparedness and response to health crises related to MCMs found that most OECD countries have entities involved in stockpiling and distribution capacities for MCMs (European Commission et al., 2025[26]). The report identified a trend towards the centralisation of strategic stockpiling at the national level, although some countries, particularly in Europe, also maintain decentralised approaches that complement national reserves (ibid). Responsibility of national emergency stockpiles often lies with government authorities (e.g. in Australia, Canada, Colombia, Korea, the United States – see Annex 9.A), although different types of arrangements are possible such as when private companies are required to maintain publicly mandated stockpiles. Several countries use mixed models, whereby the presence of nationally financed and managed public physical stockpiles may be complemented by private stockpiles or pre‑arranged access agreements. Box 9.2, for example, overviews existing or planned stockpiling systems for antimicrobials, while Annex 9.A explains Switzerland’s compulsory rolling stockpiling system.
While not directly related to pandemic preparedness and response, a review by HERA found that 13 of 20 EU and European Free Trade Agreement countries reported having a national stockpile that included antimicrobials, either as finished products and/or active pharmaceutical ingredients (European Commission, 2022[10]). As shown in Figure 9.2, countries use different governance models for these stockpiles, with 8 countries reporting a physical stockpile managed by public authorities and fully financed by national (public) funds. Other countries such as Finland and France make use of privately owned stockpiles whereby companies and wholesalers are obligated to keep certain levels of stock. In France, companies are not compensated for this obligatory stockpiling and compliance is exercised through fines for non-compliance, while in Finland companies are compensated for this stockholding by payers through higher prices. Several countries including Belgium, Sweden and Poland use a mix of governance systems. In most countries, stockpiles are managed by national authorities. The presence of regional-level stockpiles (Denmark and Sweden) and hospital-level stockpiles (Austria, Finland, Norway) were also reported.
Note: 1. Physical stockpile managed by public authorities and fully financed by national funds.
1. Companies or wholesalers are under obligations to increase their inventories to a defined level.
Source: (OECD, 2024[2]), originally adapted from European Commission (2022[10]), HERA AMR feasibility study on stockpiling, https://op.europa.eu/en/publication-detail/-/publication/712bbfff‑801e‑11ed‑9887‑01aa75ed71a1.
In HIQA’s review, France, Latvia, Lithuania, the Netherlands and Norway all reported physical2 stockpiles of MCMs, which were mainly held by governments and designed for national and cross-border threats (HIQA, 2023[9]). Government ministries were ultimately responsible for national stockpile governance, with stockpile management the responsibility of the associated governing body. Stockpiling practices in these countries are governed by national legislation, with three of the countries requiring maintenance of general medicines by wholesalers, and two other countries regulating government- or public body-held stockpiles. Medical institutions such as hospitals and other healthcare institutions reportedly held their own stockpiles in four countries. One country reported involvement of a national stockpile management group, which oversees reviewing the stockpile, ensuring minimised stock wastage and that appropriate product quantities are maintained in the stockpiles (HIQA, 2023[9]). A recommendation emerging from the HIQA report was that future stockpiling approaches should consider an active stockpile management group to manage the day-to-day of the stockpile, while also considering decentralised stockpiles distributed geographically across the country to ensure access albeit remaining under centralised co‑ordination (HIQA, 2023[9]). The United States and Australia both have centrally co‑ordinated decentralised stockpiles strategically distributed in undisclosed locations to facilitate timely deployment (see Box 9.1 and Annex 9.A).
9.3.3. Funding/reimbursement arrangements
Funding arrangements also differ across countries, depending on the stockpile approach. According to the HIQA report, public sector stockpiles in the five reviewed countries were fully funded by public funds from national budgets, however in three of the countries, stockpiles for general medicines were privately owned in industry stockpiles – either held by wholesalers or companies (HIQA, 2023[9]). Out of the five countries, only three disclosed their funding sources: one relies on central government funding, another on inter-ministerial funding, and the third on the Department of Health. In one country, a national centre managed the budget, while another had a cost framework which outlined the maximum amount to be spent on the stockpile. The other countries mentioned that their stockpile budget depended on government approval (HIQA, 2023[9]). In the United States, federal funds are allocated annually towards the Strategic National Stockpile (Box 9.1). In systems whereby companies are obligated to hold certain stock, such as in France and Finland, different compensation mechanisms exist (Box 9.2).
9.3.4. Inventory management and logistics
Stringent inventory management and sound distribution practices are paramount to the effective functioning and deployment of stockpiles. National agencies with experience in stockpiling and preparedness typically oversee procurement, although hospital procurement groups may also be involved. Stockpile procurement is, however, reportedly affected by global supply shortages, as well as long lead times with the production of some products (e.g. vaccines), and issues around supplier reliability (HIQA, 2023[9]). To prevent waste and ensure efficient stockpile management, most countries report using rotating stocks (European Commission, 2022[10]). Medicines approaching their expiry dates can be reintroduced to the market via wholesalers or directly transferred to hospitals. Publicly owned stockpiles have also reported donating medicines to other countries. Privately-owned stockpiles typically rotate their inventory back into the commercial supply chain, with each country imposing different requirements on stockpile volumes (European Commission, 2022[10]). The United States also has an interesting programme that can extend the shelf-life of some federally stockpiled products (see Box 9.1). Further to stock management, operational delivery, such as stockpile distribution, generally takes place through defined mechanisms guided by the ministry of health and in some cases inter-ministerial collaboration, as well as through wholesaler distribution networks and national emergency medical service (HIQA, 2023[9]).
Enhancing cross-country co‑operation could improve the sustainability and efficiency of stockpiling schemes. One challenge with national stockpiling policies is that accumulating larger quantities of essential medical supplies at national or subnational levels may lead to unintended consequences, such as shortages for regular use, price increases, and wastage of unused stock. Collaboration on stockpiling both during and outside of pandemic emergencies is one of the aims of the WHO Pandemic Agreement, which establishes a Global Supply Chain and Logistics Network to co‑ordinate international efforts in ensuring timely and efficient access to pandemic-related health products (WHO, 2025[5]).
Regional stockpiling and pooled procurement can be considered a more pragmatic option in some cases, provided that allocation of products during times of crises are well defined (OECD, 2024[2]). For example, under the EU Civil Protection Mechanism’s rescEU initiative, the European Commission established a regional strategic stockpiling mechanism in 2020 aimed at preparing and responding to health crises and large‑scale disasters (EC, 2024[27]) – see Box 9.3 for further details. The rescEU stockpile reserves of medical countermeasures serve as stockpiles of last resort against priority threats including pathogens with pandemic potential, antimicrobial resistance and CBRN hosted geographically across several Member States, from which Member States and associated countries can request assistance in the event of an emergency to which they do not have sufficient capacity to respond. The European Commission fully fund the rescEU stockpiles in part through the Health Emergency Preparedness and Response Authority (HERA) and maintains control of their operation through DG ECHO, in close co‑operation with the hosting states that manage the physical stockpiles and handle logistics and procurement. EU Member States and the 10 Participating States of the European Civil Protection Mechanism can request assistance from the EU Civil Protection Mechanism through the Emergency Response Co‑ordination Centre, an EU body responsible for co‑ordinating civil protection activities. This centre evaluates the ability of rescEU to support the country’s request and deploys the appropriate resources (EC, 2024[27]; HERA, 2024[28]; HERA, 2023[8]).
In 2022 and 2023, EUR 1.2 billion from the European Commission’s Health Emergency Preparedness and Response Authority (HERA) budget has been invested in building up rescEU stockpiles against serious cross-border threats, including health crises such as COVID‑19 and chemical, biological, radiological and nuclear (CBRN) emergencies including large‑scale human induced disasters (HERA, 2023[8]; DG Sante, 2023[29]). In co‑operation with HERA and DG ECHO, there are currently 22 rescEU stockpiles strategically hosted across 16 EU Member States that are either operational, being developed, or in the process of signature ( (EC, 2024[27]) see Table 9.2. ). The stock covers the three priority threats identified by HERA (pathogens with pandemic potential, antimicrobial resistance and CBRN) (EC, 2022[7]). Fifteen of the rescEU stockpiles are medical stockpiles, progressively available from 2020 onwards (EC, 2020[30]), that contain products such as vaccines and therapeutics, intensive care medical equipment, personal protective equipment and other laboratory supplies. Six of the rescEU stockpiles are CBRN-specific stockpiles, progressively available from 2023 onwards (EC, 2023[31]), and contain CBRN medical countermeasures such as vaccines, antidotes, antibiotics, sedatives, prophylactic treatment, medical devices and CBRN response equipment such as iodine thyroid blocking tablets, detectors and decontamination supplies and PPE (e.g. gas masks, protection suits). Collectively, the stockpiles form a flexible network of supply hubs that can be rapidly mobilised in the event of a crisis as a last resort (HERA, 2024[28]; EC, 2024[27]).
Note: 1. Stockpiles in hosting countries may already be operational, are being developed or are under signature.
1. Hosting countries may only store selected items from these lists in their stockpiles, in varying quantities.
Source: Adapted from ERCC (2024[32]), “ECHO Daily Map of 27 March 2024”, https://erccportal.jrc.ec.europa.eu/ECHO-Products/Maps#/maps/4832 and ERCC (2024[33]), “ECHO Daily Map of 05 June 2024”, https://erccportal.jrc.ec.europa.eu/ECHO-Products/Maps#/maps/4887.
The development, management and maintenance of the rescEU stockpiles is completely financed by the European Commission. So far, the stockpiles have been established through direct grants to Member States, and the EU Member States and Partner States own the capabilities and are responsible for procurement, management, deployment, staffing and training (Annex 2, (EC, 2025[34])). HERA offers operational support and advice on medical countermeasures, their stockpiling and deployment to the EU Civil Protection Mechanism (HERA, 2024[28]). Priorities and needs are defined by the European Commission in consultation with Member States and Partner States authorities, with decision on the deployment made by the European Commission (Annex 2, (EC, 2025[34])). According to HERA’s State of Health Preparedness report published in 2023, over 3 million protective masks, ventilators and other equipment have been distributed from the strategic rescEU centres to the Member States in greatest need since 2020 (DG Sante, 2023[29]).
The composition of the different stockpiles varies, with grant agreements of different amounts awarded to the hosting countries. As an example, Germany received EUR 108 million from EU funds to set up its rescEU medical stockpile for a period of seven years from 1 January 2021 until 31 December 2027. The stockpile intends to include “around 110 million gloves, 24 million Type II(R) medical masks, 2.5 million FFP2/FFP3 masks, 8 million protective gowns and coveralls, 1 million visors and goggles, 600 000 rapid antigen tests against COVID-19 and 1 000 patient monitors, as well as protective equipment for Ebola treatment (including rubber boots, surgical clothing, biohazard bags, body bags)” (Johanniter International, 2021[35]). Johanniter-Unfall-Hilfe, a non-profit aid organisation, leads the consortium that is in charge of operationally running the German stockpile, including the German Red Cross. The Federal Ministry of Health and the Robert Koch Institute are among those represented in an advisory group.
In its 2024 workplan, HERA sought to enhance its strategic stockpiling approach through joint actions under the EU4Health programme – via direct grants of EUR 10 million to Member States – to support MS to develop sustainable and forward looking national and EU stockpiling strategies in an efficient and co‑ordinated manner (HERA, 2023[8]). The funding aims to promote the sharing of best practices in innovative stockpiling solutions, evidence‑based strategies, and risk-based approaches, while enhancing networking and collaboration among Member States, allowing them to experiment with innovative stockpiling methods, such as virtual stockpiling arrangements and IT solutions. Virtual (or vendor-managed) stockpiles are where companies that make or sell the items store a certain amount of stock that the government can buy if and when needed (ibid). In HERA’s 2025 workplan, HERA further intends to continue to support Member States in quantifying stockpiles and establishing a network of regional stockpile and distribution hubs, as well as developing and deploying new technologies for stockpile management (HERA, 2025[36]). In 2025, HERA plans to work closely with Member States and other Commission services to address challenges in stockpiling management, such as product shelf-life, legal status, marketing authorisation, waste and deployment (HERA, 2025[36]).
Note: As discussed further in the main text, the European Commission has recently devised several strategic plans in the context of prepared and response, including to support EU stockpiling policies (EC, 2025[34]; EC, 2025[37]).
The rescEU stockpiles of medical and CBRN countermeasures are seen to have offered an effective contingency for preparedness (EC, 2025[38]). However, stockpiling medical products is a complex exercise, with many different factors to consider (including shelf-life, regulatory requirements, environment and security requirements, and transport), requiring strong co‑ordination with EU and national authorities and experts (EC, 2025[38]). As part of a broader EU medical countermeasures strategy released in July 2025 that aims to reinforce preparedness for priority threats (viruses with pandemic or epidemic potential, AMR and CBRN) (EC, 2025[34]), the European Commission has devised a strategic plan specifically for EU medical countermeasure stockpiling (Annex 2, (EC, 2025[34])). The latter is the first sectoral deliverable of a broader EU stockpiling strategy (EC, 2025[37]), which is a cross-sectoral strategy to ensure timely and equitable access to a wide range of critical goods, including medical supplies, energy equipment, critical raw materials, and potentially food and water, by integrating national and EU-level reserves, enhancing co‑ordination among Member States, and fostering public-private partnerships for efficient and scalable stockpiling (EC, 2025[37]). The specific strategic plan for EU medical countermeasure stockpiling acknowledges the complexity of stockpiling such products as described above and outlines detailed processes that intend to complement national and global initiatives, including:
Determining the needs for EU stockpiles e.g. identifying essential MCMs through a specific methodology based on specific criteria such as potential impact, time‑critical effectiveness, redundancy, market failure/limitations, and production capacity; and determining necessary quantities to be stockpiled;
Effective procurement e.g. stronger co‑ordination by the European Commission and exploring the options for procurement such as of unfinished products;
Efficient management of stocks e.g. centralised, sustainable and cost-effective management framework; integrating IT tools for real-time tracking; implementing shelf-life extension programmes; and fostering stakeholder collaboration; and
Timely deployment e.g. resilient logistics services and compliance with regulatory requirements; and determining replenishment needs with the plan to secure minimum EU-level buffer stocks. and for identifying essential medical countermeasures, determining necessary quantities and the potential need for replenishment, followed by effective procurement strategies. The plan also outlines elements to strengthen the efficient management of these stocks to guarantee readiness and timely access during emergencies as well as a deployment strategy.
More broadly, while regional stockpiling such as the EU example offers important efficiencies, it may not be feasible in all contexts. Countries with geographic isolation, long supply chain distances and reliance on imports may face greater supply chain vulnerability, limited access to nearby partners and differing logistical conditions. In these settings, a strong, nationally controlled stockpile supported by stable funding and modern capability is important and may require larger buffer stocks and diversified supplier arrangements. Nevertheless, key elements of regional methodologies and approaches, such as structured risk assessment and prioritisation, robust inventory management and digital visibility, can still be adopted.
Stockpiling policies have several practical challenges, including but not limited to financial sustainability, uncertainty and predictability, logistical and stock management challenges as well as co‑ordination issues. As previously highlighted in the OECD report on medical supply chains, assessing the costs and benefits of stockpiling policies is particularly challenging as evidence on the costs and cost-effectiveness of stockpiling are sparse (OECD, 2024[2]). Countries may not use a formal methodology to assess the costs and benefits of their stockpiling strategies (HIQA, 2023[9]). Yet, evaluations of the performance of stockpiling systems can importantly highlight some of the challenges faced in their implementation and deployment, as seen with the U.S. Strategic National Stockpile and the Australian National Medical Stockpile during the COVID‑19 pandemic (Australian National Audit Office, 2021[39]; Congressional Research Service, 2023[12]; US Government Accountability Office, 2024[40]).
Some examples of these challenges are described below, although these will differ depending on the stockpiling approach taken (e.g. public versus private, physical versus virtual).
Financial sustainability: Creating a stockpile requires a significant amount of investment, in terms of setting up the initial stockpile (including acquisition and storage) as well as ongoing maintenance requiring sustainable multi-year funding (see Chapter 8). In the United States, the 2021 annual budget for the SNS and BioShield Project3 was USD 1.7 billion, excluding additional budget that was allocated to respond to COVID‑19 (Congressional Research Service, 2023[12]). Administration for Strategic Preparedness and Response officials have reportedly mentioned that annual allocation of funds to the SNS are insufficient to cover the costs associated with responding to the increase in threats for which the SNS may be needed (Congressional Research Service, 2023[12]). For example, while the 2022 budget for the SNS was USD 845 million, projections from 2019 indicated that USD 1.04 billion would be needed just to stockpile supplies against two threats, anthrax and smallpox (Congressional Research Service, 2023[12]). Box 9.1 gives insight into the magnitude of the annual funds needed for the procurement and maintenance of stockpiled holdings of medical countermeasures in the U.S. context. In Australia, the value of products in the national stockpile in 2019 was estimated at AUD 123.1 million, corresponding to USD 85.5 million (Australian National Audit Office, 2021[39]). The EU strategic plan for MCMs will feed into future funding discussions on EU-level stockpiles, acknowledging that it takes a “long-term commitment and requires sustainable funding” (Annex 2, (EC, 2025[34])).
Budget constraints can reportedly limit decisions on stockpile contents, and countries may have difficulties in reaching agreements with industry stakeholders to maintain stockpiles (HIQA, 2023[9]). Costs of the maintenance of a stockpile, however, also need to be weighed against the alternative of procuring goods during a crisis event, in the context of high demand and potential supply disruptions. For example, an academic study in the United States estimated that buying PPE at non-pandemic prices to stockpile would cost only 17% of the amount needed to procure it during a pandemic, and that maintaining the stockpile would cost less than buying it during the pandemic even if it is not required for 35 years (Dow, Lee and Lucia, 2020[41]).
Uncertainty and predictability: The virulence and infectiousness of future pathogens of pandemic potential are unpredictable, making it difficult to determine what and how much to stockpile. For example, Plans-Rubio (2020[42]) highlighted several difficulties in analysing the cost-effectiveness of stockpiling vaccines, antiviral treatment and ventilators as a pandemic preparedness and response strategy, one of which being that that the effectiveness of the stockpiled vaccines against the future pathogen is unknown. Another paper reported that incremental cost-effectiveness of stockpiled pneumococcal vaccines against developing secondary bacterial infections during influenza pandemics is dependent on the replacement costs of the stockpile (i.e. whether the entire stockpile needs to be fully replenished at the end of its shelf life, incurring significant replacement costs, or if it can be rotated into the routine healthcare system) (Dhankhar, Dasbach and Elbasha, 2009[43]).
Logistical and stock management challenges: Proper management of stockpiles requires robust logistics, including inventory management systems and regular rotation of stock. An early evaluation of the U.S. SNS system during COVID‑19, for example, noted that a lack of market intelligence (i.e. knowledge of suppliers, capacity and risks) and poor visibility into supply capacity hindered its ability to procure products (Handfield et al., 2020[44]). In addition, insufficient inventory management practices such as the proper use of barcode tracking and strategic forecasting limited its ability to anticipate shortages and supply needs (Handfield et al., 2020[44]).
Stockpiled items also have limited shelf lives and regular cycling out and replacing of expired items is necessary to ensure the stockpile remains viable and effective. Waste management has been identified as a notable issue with stockpiling policies, however countries note that while wastage cannot be completely avoided (particularly for products that may not ever be required and cannot be cycled out of the stockpile), it can be managed or minimised (HIQA, 2023[9]).
Co‑ordination and communication issues: Challenges with stakeholder co‑ordination and communication can hamper the stockpile’s effectiveness during a crisis. Effective stockpiling and deployment require co‑ordination, communication and information sharing between various stakeholders, including public authorities (national, local, and in some cases internationally), health service providers (hospitals, pharmacies, primary healthcare facilities and other medical institutions etc), industry manufacturers, and distributors and logistics providers etc. Internal audits of the Australian Government-managed National Medical Stockpile found mixed feedback on the effectiveness of communications about the National Medical Stockpile procurement and deployments to state and territory health authorities and primary care sector during COVID‑19. (Australian National Audit Office, 2021[39]). Handfield’s evaluation of the U.S. SNS reported structural weaknesses in engaging stakeholders on both the supply and demand sides (Handfield et al., 2020[44]). A more recent report by the U.S. Government Accountability Office (2024[40]) similarly highlighted challenges faced during COVID‑19 such as unclear agency roles, outdated guidance, poor communication on asset requests and deliveries, and limited transparency of inventory However, in response, HHS has begun updating guidance, clarifying responsibilities and better planning co‑ordination with local authorities to enhance future emergency preparedness (US Government Accountability Office, 2024[40]). In Switzerland, international co‑ordination and global market oversight were highlighted as key areas for improvement in public audits of its rolling stockpile system, whereby stockpiles are maintained and owed by private companies but the Federal Office of National Economic Supply determines what should be stockpiled and when it should be released (FOPH, 2022[45]). France, Latvia, Lithuania, the Netherlands and Norway participated in EU-wide stockpiling initiatives and reported a gap in stockpiling co‑ordination between EU countries (HIQA, 2023[9]).
This special focus chapter provided an overview of policies for stockpiling medical goods as a short-term buffer layer for pandemic preparedness and response. Drawing on insights from several OECD countries and the European Union, it indicates that stockpiling of relevant medical goods is considered an important component of timely and effective pandemic preparedness and response capacity, albeit offering a finite supply and limited effectiveness during prolonged disruptions. Beyond pandemics, stockpiling supports responses to natural disasters, chemical, biological, radiological and nuclear threats, as well as the threat of antimicrobial resistance.
The analysis highlights that effective stockpiling policies require strategic planning and risk assessment, clear governance structures, sustainable funding, and effective management of risks and inventory. The findings also underline the importance of stockpiling initiatives that are strategic and co‑ordinated, to ensure timely and efficient access to medical products for all worldwide.
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Source: Adapted from (OECD, 2024[2]).
← 1. Medical countermeasures (MCMs) diagnose, prevent, protect from, or treat conditions during a public health emergency. Examples include vaccines, antibiotics, antivirals, medical equipment, chemical antidotes, therapeutics, diagnostic tests or personal protective equipment such as gloves or masks (FEMA, 2023[53]).
← 2. Physical stockpiles hold physical items in warehouses that can be immediately deployed in the event of an emergency. Virtual (or vendor-managed) stockpiles are another option, where companies that make or sell the items store a certain amount of stock that the government can buy if and when needed.
← 3. The SNS comprises U.S. Food and Drug Administration – approved medicines, vaccines, and other medical countermeasures. The BioShield project enhances the SNS by adding 25 products, which include vaccines for anthrax and smallpox, as well as treatments for anthrax, botulism, nerve agents, radiation exposure, and thermal burns (Congressional Research Service, 2023[12]).