As the Ukrainian population takes cover and entrenches its resistance to the Russian invasion, Ukraine’s health minister Viktor Lyashko has pushed for ‘business as usual’ within the healthcare system, but much ingenuity and support are needed in an environment where stocks of medical supplies are already running out.

Only two weeks ago, the Ukrainian parliament was evaluating the latest steps in the modernisation of the state-guaranteed Ukrainian National Health Service (NSZU) under a newly increased budget, including guaranteed minimum wages for medical staff and enhancements to specialist care. The World Health Organisation (WHO) had been closely supporting these plans as the nation emerged from the Covid-19 pandemic. All these plans, however, were derailed by Russia’s sudden invasion days later, and martial law took precedence.

Initial steps under martial law

In the face of the sudden crisis, which was initially exacerbated by cyberattacks on government communications, the Ministry of Health (MoH) still managed to release initial emergency calls for volunteer staff, blood donations and international aid. It also cancelled elective hospital procedures to make way for emergencies. This was followed by more practical steps, the first being a simplification of funding mechanisms to ensure continuous support for medical facilities while under martial law. In addition, the MoH advised hospitals to negotiate direct supply contracts with manufacturers for drugs, diagnostics and dressings, circumventing the usual tendering procedures.

Community pharmacists – resourcefulness under pressure

While community pharmacists were urged from the outset to keep all outlets open for the public, this was only possible in some locations. There was a predictable spike in demand for medicines and first-aid items from the first day of the invasion, as documented by Ukrainian analysts Pharmexa, followed by a rapid dwindling of available stocks of essential medicines, which became increasingly hard to replenish as transport links were disrupted and orders became more difficult.

At this point, the Pharmacy Professional Association of Ukraine (APAU) sent out an urgent call to suppliers to allow deferred payments and simplified contracts, especially for the replenishment of local stocks of painkillers, antipyretics, haemostatics and dressings. In Kyiv, local pharmacies advertised a telephone ordering scheme for home deliveries of medicines from stocks in boarded-up premises. The MoH also reverted to allowing paper prescriptions for reimbursed medicines for outpatients with chronic conditions.

Such measures, however, could only be short-term fixes, with reports already emerging of pharmacies being looted and hospital facilities being destroyed. The WHO has now called for a humanitarian corridor to be opened up to deliver medical supplies to the most troubled regions. While hope still remains for the government to fight towards a period of stability and rebuilding of services, it is hard to imagine how desperate the situation may become if the fighting continues in the long term in major parts of the country.

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The tainting of Russian trade – only the beginning

Russia’s position is, comparatively, more complex than that of Ukraine, and the Russian government will have to deal with a tainted international reputation from which it will likely take a long time to recover. While direct sanctions on medicines are off the international agenda and likely to remain so, the many punitive measures that have already been imposed will nonetheless have knock-on detrimental effects on access to healthcare and medicines in Russia.

The Association of Russian Pharmaceutical Manufacturers (ARPM) has warned that European suppliers have already begun to block the transport of pharmaceutical raw materials to Russian sites, and that follow-on supply contracts have been almost impossible to secure. Several sanctioned financiers such as Sberbank and the Russian Direct Investment Fund (RDIF) have been major sponsors of the pharma industry, with the RDIF notably sponsoring exports of the high-profile Sputnik V Covid-19 vaccine. Alongside this, the economic effects of the plummeting Ruble are already being felt, and there is a strong likelihood of drug withdrawals and shortages as manufacturing and import costs become unsustainable.

In addition to measures such as import substitution strategies, the Russian government has also been examining more creative angles to try to circumvent the effects of sanctions, such as a broadening of compulsory licensing permissions and routing supplies via other members of the Eurasian Economic Union (Belarus, Kazakhstan, Kyrgyzstan and Armenia). Such measures are, however, unlikely to ameliorate the major economic blow to Russia’s trading position, which is also likely to send shock waves across neighbouring Eurasian markets, many of which trade closely with Russia while trying to retain a political distance. The damage to Russia’s economy and trade is likely only just beginning, and the longer the conflict persists, the harder it will be for the country to recover.