The Pharmaceutical Journal Vol 266 No 7150 p763-764 June 2, 2001

Articles

Pharmacy in Estonia

Pamela Mason visited Estonia recently and look at how pharmacy is practised in that country. Here, she reports what she found

Estonia with a population of 1.47 million, is the smallest and most northerly of the three Baltic republics. Since gaining its independence from the Soviet Union in 1991, Estonia seems to have been able to make the transition to a free market economy less painfully than the other two Baltic republics Latvia and Lithuania, thanks partly to its close links with Finland, which is just 50 miles away across the Gulf of Finland. This easy transition is also evident in pharmacy, where co-operation with the Finnish pharmaceutical association had led to the establishment of similar systems, for example, for reimbursement for medicines. Although all such systems were initiated locally in Estonia, collaboration with other countries was helpful, particularly during the early 1990s, because of the urgent need to create a workable system to replace the centralised Soviet model of direct state provision where all medicines were free of charge. Estonia, like Russia, has suffered from a decline in health status since 1990. By 1994 life expectancy in men had fallen to 61.1 years from 66.5 years in 1989. In women, the fall was not so dramatic, with life expectancy being 74.9 years in 1989 and 73.1 years in 1994. Although life expectancy has been increasing since, Estonian men can still expect to die 10 years younger than men in the United Kingdom. Privatisation As in many of the former Soviet bloc countries, community pharmacies in Estonia were privatised after independence, and today 267 of the 273 pharmacies are privately owned. Anita Gailan, a sales manager for a pharmaceutical company, told me that privatisation started in 1992 and was almost complete by 1995 with many of the pharmacists employed in the old state pharmacies being quick to make the most of the opportunity to buy the pharmacy in which they worked. Having to buy only the stock and the fixtures and fittings, but not the premises, meant that the price was cheap and many pharmacists have undoubtedly made a good investment. Moreover, the number of pharmacies has grown by only 15 per cent in the 10 years since independence, which although a large increase by UK standards, is tiny by comparison with some other eastern European countries where a larger number of small, new, private pharmacies opened almost overnight. Latvia, for example, witnessed its number of community pharmacies increase by 60 per cent during the same period. Rita Makarova is one of the pharmacists who bought a pharmacy in the 1990s. Situated in a small shopping precinct on the edge of the capital city of Tallinn, her pharmacy, Oismae Apteek, is 20 years old, but as a result of recent refurbishment, it looks much newer. As an old state pharmacy, it is massive, and most UK pharmacies would dispense the same number of prescriptions — 300 to 400 a day — in probably a quarter of the space. In addition, the supply of prescriptions and over-the-counter medicines from two completely separate areas of the pharmacy would be difficult to supervise for a pharmacist working alone. But Ms Makarova employs 10 pharmacists, of whom at least two or three will always be on duty. However, compared with 10 years ago, this is a small number — then, the pharmacy used to have twice as many staff as it does today. One thing that has increased in the past decade has been the number of pharmaceutical wholesalers. In the Soviet times, there was just one state wholesaler which delivered once a month, and it would take most of the three days after the delivery to unpack the stock and put it away. Today, there are more than 30 wholesalers — far too many, pharmacists say — but to get the best prices means buying from most of them, even if it is only one item from one wholesaler, and pharmacies in urban areas are now used to getting four or five deliveries a day. Income Community pharmacists earn their income in much as the same way as their British counterparts from sales of OTC medicines and prescriptions. But the OTC business, although growing, rarely represents more than 10 per cent of a pharmacy’s turnover. The reimbursement system for prescription medicines, which was developed in 1993 and is similar to the Finnish model, is more complex than the UK one, as I could see from the three or four bundles of prescriptions on Ms Makarova’s desk waiting to be sent off for pricing. In Estonia it is not just a matter of separating prescriptions into paid and exempt categories. Indeed, there is no exempt category. Whatever the cost of the medicine or the age of the patient, everyone has to pay at least 20 Estonian kroons (about 80p) to start with. In excess of that amount, certain drugs can be reimbursed either totally or at 90 per cent by the Sick Fund. Reimbursable drugs are on a positive list based on the World Health Organization and the Estonian essentials drug list. However, not all prescription medicines appear on the positive list, but for drugs not on the list and costing from 50 to 200 kroons, 50 per cent of that cost is still reimbursable. The cost of reimbursable drugs and other health care costs are covered by a system of health insurance, which started in 1992 as part of the process which aimed to decentralise health care financing. Health insurance represents 13 per cent of an employee’s salary and is collected as part of income tax. The other source of health care finance is general taxation through state and municipal budgets and, since the advent of the new system, there has been much discussion on the proportionate allocation of resources from the health insurance funds and the state and municipal budgets. This is mainly because of shortage of money in both “pots” and the need for large amounts of money for renovation and maintenance of dilapidated hospitals and clinics, and also for improvements in services, which increasingly well informed patients demand. Hospital pharmacy The hospital pharmacy I visited on the edge of Tallinn was anything but dilapidated. Serving 610 beds, the pharmacy employed 17 staff, five of whom were pharmacists, and the department, again newly refurbished, was in pristine condition. Chief pharmacist Ruth Soosaar is justly proud of the pharmacy with its sterile production unit which includes a new laminar flow cabinet. About half of the hospital’s requirements for intravenous fluids — about 500 500ml bottles each day — are made on site and the other half is bought from wholesalers. Two or three members of staff are involved in bottle washing for a significant proportion of the day. Production and supply are still the main focus of the work in hospital pharmacies and pharmacists do not visit the wards. Neither do they dispense for outpatients. University pharmacy One of the few community pharmacies which is not privately owned is the university pharmacy in Tartu, Estonia’s second city. The pharmacy has been almost totally refurbished, again with a separate area for prescriptions and OTC medicines and also a third area for veterinary medicines. The veterinary area is managed by graduates from the local agricultural college. But behind the scenes in the staff room the “old” and the “new” are in intriguing juxtaposition. The kitchen consists of a huge stainless steel sink surrounded by white tiles and a linoleum floor, while a pine table, and chairs with bright red and white check cushions grace the dining area. And it is all kept well scrubbed by a couple of cleaners. Following the passing of a new medicines law in 1995, the state agency of medicines, which is responsible for pharmacy inspection and granting of pharmacy licencses, is raising standards all the time. Maila Madise, the director of the university pharmacy, explained that a pharmacy has to have separate areas for accepting deliveries, unpacking, dispensing and administration, and the sizes of the different rooms are laid down in the standards. Licences are granted for a five-year period and, if pharmacies do not fulfil the requirements, they will not be able to renew their licence. One of the aims of the standards, she told me, is to ensure that pharmacies do not just become kiosks that sell medicines without professional advice. This is an appropriate aim — and the aim of pharmacists worldwide — and it is clear that the large pharmacies in Estonia, inherited from the Soviet period, afford the luxury of space which makes these standards possible. Imagine having separate rooms for checking off drug deliveries and counting the day’s takings in every UK pharmacy! Education Tartu is also home to Estonia’s only department of pharmacy. This means that many pharmacists in Estonia know one another personally. According to Professor Peep Veski (the head of department), the pharmacy curriculum was redesigned in 1997 to fit in with European Union requirements and to support the teaching of pharmaceutical care. The course is five and a half years long, including six months’ practical experience in a pharmacy. University education is still largely free in Estonia, although accommodation has to be paid for. Both students I met, Maia Remmelgass and Andres Seppa, the president of the Tartu university pharmacy student association, find the rents, which average between 900 and 1,200 kroons a month, expensive, and students are increasingly taking on part-time work to help make ends meet. Unlike in Britain, the number of male pharmacy undergraduates is increasing, Mr Seppa told me. Traditionally, most health professionals in the former Soviet bloc countries were women, but pharmacy is attracting more men now because they believe it is a good way to make money. Old pharmacy The capital city of Tallinn boasts what is believed to be one of the longest — if not the oldest — continually functioning pharmacies in Europe. Mention was first made of this pharmacy, which is situated on the north side of the town square, in 1422. One of its early occupants was Johan Buchardt, a salesman, whose family eventually bought it. The pharmacy then passed through several generations of the same family, one of whom was a doctor sent for by Peter the Great to tend him on his death bed. (The tsar died before the doctor got there.) The building, whose present façade dates from the 17th century, has been renovated several times over the years, and is being refurbished again now, ready for opening within the next few months. The pharmacist who will manage the pharmacy, Liia Vollrat, is intending to keep one room as a pharmacy museum, but the rest will be run as a modern pharmacy, albeit with early 20th century fittings. But she will continue the tradition of making and selling the pharmacy’s special recipe claret, a mixture of German wine and spices, and also the marzipan sweets, which I was able to enjoy on the day of my visit. Conclusion Pharmacy services in Estonia have undergone considerable change during the past 10 years. Creation of appropriate legislation, establishment of regulatory authorities and a drug reimbursement system have all been achieved as has privatisation of community pharmacy. Further improvement is necessary in certain areas, as it always is, but pharmacists have had a lot to get to grips with, such as running a business, learning about the rapidly increasing number of drugs available on the market as well as explaining the new systems to patients. However, all these changes do not yet reflect the ultimate goal of the Estonian pharmacy profession — that is to provide pharmaceutical care. In the words of Ms Makarova, “we have to adapt not only to change around us, but we also have to change ourselves;” the biggest challenge of all — just as it is in the UK.

Dr Pamela Mason is a pharmacist and freelance writer from Sydenham, South London

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