Applying the Delphi Method to Develop a NATO Pharmaceutical Stockpile in Support of the Center of Excellence for Military Medicine

Introduction: Recent global events including the Russian invasion of Ukraine have caused major disruptions to medical supply chains, highlighting the fragility of just-in-time logistics models and the risks posed by overreliance on foreign manufacturing capabilities. The transition from peacetime to crisis—and from crisis to full-scale conflict—demands rapid escalations in supply of pharmaceuticals. The objective of this research was to develop a consensus-driven list of high priority critical medicines as a basis for the creation of a North Atlantic Treaty Organization (NATO) pharmaceutical stockpile. Materials and Methods: This Delphi Panel completed work started by the NATO Center of Excellence for Military Medicine to identify critical medications in July 2024. The panel involved collecting feedback across two rounds of voting from a group of subject-matter experts with background in combat casualty care and pharmaceuticals, with the goal of rating a list of critical medications on three factors on a Likert scale of 1 (low) to 9 (high): overall priority, use above baseline, and availability of alternatives. Median scores and tertiles were calculated to rate the medications in order of priority based on the aggregate statistics. Results were presented and finalized at a NATO-sponsored workshop in Poland as the final round of the Delphi in May 2025. Results: The first round of the Delphi, conducted in February 2025, was a virtual, asynchronous voting round where 28 respondents participated rating and refining the initial list of 107 medications. Based on these results, 26 medications were determined high priority for stockpiling and 20 were removed from consideration. The second round took place in March 2025, and consisted of synchronous, virtual voting on the 61 medications of “uncertain priority” in the previous round. As a result, two additional medications were added to the high priority category for inclusion in stockpiles, with the final list presented for discussion in person during Round 3 containing a total of 28 critical medicines rated “high priority.” Additionally, Rounds 2 and 3 resulted in discussion of alternative medications not included in the list, such as treatments for CBRNE exposures and viable alternatives for listed medications. Conclusions: Ensuring availability of critical medicines during military operations and humanitarian emergencies supports the health and operational readiness of military personnel and the well-being of civilians affected by crises. By developing a systematic approach for prioritizing pharmaceuticals, this project addresses gaps in medication availability for NATO that could otherwise hinder effective response to emergencies.