While in Denmark, Dr Mason took the opportunity to visit Mr Kees de Joncheere, the regional adviser for pharmaceuticals at the World Health Organisation's regional office for Europe, who is based in Copenhagen
If you enjoy travel, sometimes at short notice to countries in crisis, and if you would like to work with a small committed team of people from different cultural backgrounds in an office in Copenhagen with a magnificent sea view, you might consider applying for Mr Kees de Joncheere's post. Not that it is vacant; nor is it likely to be. Mr de Joncheere, a Dutch pharmacist, who is currently regional adviser for pharmaceuticals at the World Health Organisation regional office for Europe, clearly loves his job. But then it is not everyone who can send an e-mail to Bosnia or Macedonia and be part of a process that promotes rational drug use in countries where this is still far from being a reality.
Created in 1948, the World Health Organisation is a specialised agency of the United Nations, and its main responsibility is international health matters and public health. It has six regional offices throughout the world of which the European office in Copenhagen is one. As Mr de Joncheere acknowledges, Europe is a very different place from what it was in 1948, and has become particularly so since the fall of the Berlin wall in 1989. Prior to 1990, the WHO European region consisted of 32 fairly sophisticated "Western" nations, but it has now grown to include a total of 51 countries with some 870 million inhabitants covering a huge area that stretches from Greenland to the Pacific coast of Russia.
Not surprisingly, much of the work during the past 10 years has focused on the problems faced by the emerging democracies of the central and eastern part of the region, although there is now renewed emphasis on the problems faced by western European countries. Disease, of course, is no respecter of boundaries, and just as AIDS has spread eastwards, diphtheria, which had been almost eliminated from western Europe, has, in recent years, been reported in Germany, Finland and Norway as a result of importation from Russia. In addition, conditions such as diabetes, chronic respiratory diseases and osteoporosis are increasing health problems in all parts of Europe, due in large part to the ageing population. And although there is a widening gap in mortality rates and life expectancy between Eastern and Western Europe - people in the European Union now live on average six years longer than those in central and eastern Europe and 11 years longer than those in the newly independent states of the former Soviet Union - all parts of Europe clearly have much to learn from each other's experiences of disease and health care delivery.
Delivery of health care clearly includes the appropriate use of drugs and the WHO "essential drugs" concept remains as important today as it was when it was launched 20 years ago. In European countries, between 10 and 30 per cent of health care expenditure is spent on medicines, but, all too frequently, scarce resources are wasted on drugs of questionable usefulness and on unnecessary drug use. This is because pharmaceutical policies are developed not only in the interests of patient health, but are also shaped by economics and the interests of the pharmaceutical industry. Moreover, in some countries, medicines are supplied without the necessary professional control and products of poor quality are a problem in several parts of Europe.
Mr de Joncheere explains that the WHO pharmaceuticals programme collaborates with countries in their policies and strategies to improve access to needed medicines at an affordable cost and to promote their appropriate use. This involves careful use of public and private expenditure - a particularly important issue in eastern European countries where, until 10 years ago, health care was delivered entirely by the state. Governments have to think clearly how they can deliver public health objectives within systems that have rapidly privatised, and health ministers are not always clear about what it is they have to regulate. All regulatory development is supported by WHO guidelines and standards, although European Union standards are increasingly driving the regulatory agenda.
The pharmaceuticals programme looks at developments across Europe and identifies successful strategies in cost containment and optimal drug use, and shares these experiences with the other member states. Measures already adopted include positive and negative lists of drugs for reimbursement, promotion of generic prescribing, patient co-payments, prescribing budgets, price regulation, reference pricing, formularies and clinical guidelines.
Included in the pharmaceuticals programme is a large project, which in 1993 began work with the newly independent states of the former Soviet Union. Partly funded by the UK "Know How fund", the aim of this project is to improve the health status of the populations in the newly independent states, with the emphasis on appropriate and accessible drug treatment. Mr de Joncheere explains that in many newly independent states health care systems are still inappropriately structured and funded such that in many cases there has been a dramatic shift towards patients having to pay for medicines which they can ill afford. Following the demise of public funding, the number of expensive medicines in these countries has increased dramatically, changing patient's perceptions and requests for drugs for which the state will not pay. Education and training of health professionals on modern drug treatment forms a significant part of this project, with problem-based teaching becoming an increasingly used method for training, as indeed it is in Britain.
Pharmaceutical projects are also well established in Bosnia, Kosovo, Albania and Macedonia, and the desire to maintain peace in these countries will ensure the presence of the relief agencies, including the WHO for some time yet, says Mr de Joncheere. Work involves the immediate relief components and handling of drug donations as a result of the emergency as well as various developmental projects to ensure rational drug use and a measure of self sufficiency in terms of health care delivery as soon as is feasible.
The WHO is still much involved in other central and eastern European countries, but they have made a great deal of progress in the past few years, and further pharmaceutical development is now being driven by their applications to join the European Union. Although the time frame continues to be somewhat uncertain, development of the regulatory and legislative framework is non-negotiable, and one of the roles of WHO Europe is to bring people together for exchange of information and identification of successful pharmaceutical policies from other countries.
Networking is also important between and within member states of the EU, explains Mr de Joncheere. Because of an atmosphere of suspicion, there has traditionally been precious little interaction between governments and health insurance organisations of the different EU member states. Drug pricing and reimbursement, as well as issues of efficacy, quality and safety, are on every national health agenda, but it is only recently that countries have met to discuss these issues and to analyse the effectiveness of national policies in areas such as cost containment and prescribing budgets to see what they can learn from each other. Some issues such as the drawing up of pharmacoeconomic guidelines could be handled on a Europe-wide basis, suggests Mr de Joncheere and this will be discussed at further joint meetings in the future.
The pharmaceuticals programme also embraces the Europharm Forum. This is the forum of national pharmaceutical associations and WHO Europe. The forum was established in 1992 and one of its main aims is to develop pharmacy practice, mainly by encouraging pharmacists to shift from a focus on products to a focus on public health and also on medicines management at the individual patient level. The forum currently has five projects - in asthma, diabetes, hypertension, smoking cessation and "ask about your medicines" (a campaign to encourage the public to ask for advice to enable them to derive maximum benefit from their medicines). Two further initiatives in HIV/AIDS and needle exchange and in self-medication are being developed. Mr de Joncheere emphasises the need for clear measures of health outcomes and clarification of the contribution that pharmacists can make in these areas.
Although pharmaceutical developments across Europe are a source of great professional satisfaction for the staff in the WHO European office, there is never any room for complacency and slackening of effort. The challenge of getting the right drugs to the right patients and making sure they are used properly will remain for many years yet, probably far too many. And there was still one more e-mail to send to Bosnia before Mr de Joncheere could leave for the evening and then there was the packing to do for next week's trip to Hungary. Yes, I suspect many pharmacists would find doing this job a great privilege.