Jean-François Bussières, Chantal St-Arnaud, Christine Schunck, Diane Lamarre, and François ..... our pilot project, we disposed of 300 metric tons of expired.
The Role of the Pharmacist in Humanitarian Aid in BosniaHerzegovina: The Experience of Pharmaciens Sans Frontières Jean-François Bussières, Chantal St-Arnaud, Christine Schunck, Diane Lamarre, and François Jouberton
BACKGROUND: Founded in 1985, Pharmaciens Sans Frontières (PSF) is a nongovernmental organization of pharmacists involved in humanitarian aid. PSF relied on approximately 100 expatriates in 1998, which included 50 pharmacists distributed throughout 24 missions (i.e., 14 emergency, 7 development, 3 assessment). It is necessary to add 200–250 local staff to this group. OBJECTIVE: To describe PSF’s mission in Bosnia-Herzegovina from 1992 to 1999 and to define the pharmacist’s impact in the supply of medicines and the development of pharmaceutical care and services. RESULTS: In April 1992, at the beginning of Sarajevo’s siege, PSF sent a small team of three volunteer pharmacists to BosniaHerzegovina. The objective of the emergency phase (1992–1995) was to set up a massive supply program of essential medicines and medical and biologic materials and to implement a distribution system based on existing health centers. The signing of the Dayton peace agreement and a progressive return to peace and stability marked the beginning of the postemergency phase (1995–1997). This phase pursued previous objectives of establishing a distribution network and added the implementation of logistic centers. PSF widened its involvement to medical laboratory analysis, production of medicines, disposal of expired medications sent during the conflict, and the implementation of a national center for quality control. Currently, the development phase’s (1998–1999) objective is to provide adequate support for the reorganization of pharmaceutical care and services by establishing pharmacy work groups and developing and maintaining good relationships with the international community and Bosnia-Herzegovina pharmacists. CONCLUSIONS: Humanitarian aid is essential in major conflicts, as seen in the case of Bosnia-Herzegovina. Although it is difficult to evaluate the impact of the distribution network implemented by PSF, it allowed for a better provisioning of medications to the general population. PSF played an important role in such cases. In fact, PSF provides its pharmaceutical expertise to these embattled areas not only by offering financial support to the logistics or supplying of medications, but by offering professional support to the organization/reorganization of the pharmaceutical practice. KEY WORDS: Pharmaciens Sans Frontières, Bosnia-Herzegovina, humanitarian aid.
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rmed and unarmed conflicts, natural disasters, and A poverty have incited many of the humanitarian aid missions providing needed health services to act promptly. In this area of expertise, one might first think of the nurse or physician as the principal healthcare provider. However, a varied number of professionals within the healthcare system are involved, with a markedly increasing number of pharmacists. Essentially, financing comes from Western nations and is dispatched to the country requiring assistance via numerous governmental and nongovernmental organizations. In the health domain, the most representative of these organizations are the World Health Organization (WHO), CARE International, Médecins Sans Frontières, Doctors of the World, and the Red Cross. Pharmaciens Sans Frontières (PSF) is the only organization with a pharmaceutical orientation.1 Humanitarian aid is essential to many countries, but the results and impacts of programs already in place are sometimes difficult to evaluate. Several nations, where political
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and economic structures have been severely affected, find recovery difficult and may require humanitarian assistance on an almost permanent basis, to the point where such a hybrid system may be the only satisfactory solution in the long run. Other situations may lead some to believe that humanitarian relief creates a state of dependence that justifies steady financing and the presence of expatriates, while the autonomy of a country’s population is not sufficiently encouraged. Yet, humanitarian aid is the result of the good will of volunteers. These observations apply to BosniaHerzegovina.1 This article describes PSF’s mission in Bosnia-Herzegovina from 1992 to 1999 and illustrates the pharmacist’s role and potential impact with regard to the procurement of medications, as well as their contribution to the development of relief-based pharmaceutical care and services. Review of the Literature We conducted a review of the literature using MEDLINE and International Pharmaceutical Abstracts, with such key words as humanitarian aid, Pharmaciens Sans Frontières, pharmacists, pharmacy, Bosnia-Herzegovina,
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Yugoslavia, war, and drug donations. Twenty English and French articles were obtained, dating from 1985 to 1998. The literature review illustrates both the limited number of publications on humanitarian aid through pharmacists and the absence of publications on PSF.2-8 These experiences attest to the useful and necessary role a pharmacist can play in times of war or conflict in provisioning and distributing medication. No article addressed the question of support in the development and reorganization of pharmaceutical care. Some articles described the call for pharmacy technical assistants and others described medication grants.9-17 Berckmans et al.9 reported the results of a consultation led in August 1996 by the European Association for Health Development in collaboration with a dozen other organizations concerning medication donations to Bosnia-Herzegovina. This assessment, based on approximately 40% of all donations, revealed a massive arrival of inappropriate donations in Bosnia-Herzegovina. A donation is deemed inappropriate if it does not appear on the list of essential medicines published by the WHO; is expired or soon will be; is damaged; does not correspond to healthcare needs with regard to epidemiology, shape, and presentation; or is unknown to healthcare professionals in that country. It is reported that 50–60% of all donations were inappropriate in approximately 35 000 metric tons of medicines and received medical supplies between 1992 and 1996. It is necessary to mention that a shipment of expired or soon-to-be expired medications can decrease costs for the donor because imminent disposal in the country of origin is expensive. The authors suggest that donors have saved more than $25 million by giving these products to BosniaHerzegovina. Bonati et al.10 described a high volume of unusable medicines sent to Bosnia-Herzegovina, notably 250 metric tons in Mostar, 25 metric tons in Banja Luka, 20 metric tons in Bihac, and 100 metric tons in Sarajevo. It is necessary to evaluate international assistance to ensure better coordination and scheduling of donations. Hogerzeil et al.11 summarized the essential elements of an adequate grant of medicines as proposed by the WHO.
Table 1. PSF’s Principal Goals and Objectives To list and analyze the health and pharmaceutical needs of populations To give recipient countries medicines and selected material and to ensure that they arrive quickly and in good condition, while avoiding risk of misappropriation To study the best strategies of provisioning and to ensure the logistics and maintenance of missions To ensure technical aid in developing countries and to needy populations To encourage the implementation of dispensaries and public pharmacies with close ties to local authorities, international institutions, and other nongovernmental organizations To ensure the training of locals concerning the pharmaceutical structures in place and the technical aid given to organizations in need
Pharmaciens Sans Frontières PSF is a nongovernmental organization that was founded in 1985 by five French pharmacists to provide pharmacists with the opportunity to be involved in relief work. Unquestionably, pharmacists have an important role in the selection, acquisition, distribution, and organization of medication used in humanitarian aid. At best, they can facilitate the development of lasting and efficient structures for the provisioning of medications. PSF’s actions take form through missions, defined as human, financial, and material resources invested to accomplish and adapt PSF’s objectives. Table 1 presents PSF’s principal goals and objectives. There are three types of missions: emergency, development, and assessment, usually named by the country in which they occur. An www.theannals.com
emergency mission includes supplying drugs and medical materials to the health structure of the country experiencing natural, economic, or human disasters. Integrated in a real policy of public health in harmony with the principles of the WHO, the development mission aims to ensure the autonomy of the population in regard to health. An assessment mission helps determine pharmaceutical needs of a population to set up an emergency or development mission. In 1998, PSF consisted of approximately 100 expatriate pharmacists, 50 of whom were distributed throughout 24 missions (i.e., 14 emergency, 7 development, 3 assessment). In any particular mission, there is a general or pharmaceutical coordinator, an administrator, and logistics managers who permit pharmacists to work in the best possible conditions. Pharmacists are recruited by seven national associations throughout Europe, North Africa, and Canada.1 Teams of pharmacists, coordinators, administrators, and logistics managers, currently named expatriates, are augmented with local staff; this comprises the PSF field team. Generally, expatriates involved in an emergency mission stay three months to one year. To ensure continuity in the work of a development mission, expatriates stay at least six months; the voluntary engagement is usually one to two years. The continuity of the mission is permitted by the fact that each new expatriate gets a briefing, in which the departing expatriate communicates all pertinent informa-
To propose and participate in training, prevention, and sanitary education activities to promote a rational use of medication To be mobilized and to participate in all acts of environmental protection; more generally, to put one’s pharmaceutical expertise to the service of the environment To maintain ties with health professionals and, more generally, to put to good use the efficiency of the pharmaceutical network and the expertise of our profession to the service of humanitarian associations, ensuring, in the best possible conditions, the quality of the mission To bring pharmaceutical aid to countries with poor health structures by organizing information sessions, exhibitions, and conventions of local, regional, and national committees; the management of establishments; and the use of information materials for the achievement of all humanitarian missions PSF = Pharmaciens Sans Frontières.
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tion and initiates him or her to the particular political situation. In 1998, PSF had an annual budget of almost $13 million, of which less than 20% came from private funds. The main financial backers were the European Community Humanitarian Office (ECHO), the European Union Administration of Mostar (EUAM), Overseas Development Agency, and US Aid. Approximately 80% of expenses are linked to activities during missions. In 1998, PSF’s activities were distributed as follows: 45% in Eastern Europe, 17% in Asia, 14% in the Middle East, 9.5% in Eastern Africa, 5.1% in Western Africa, 5.1% in South America, and 4.2% in other areas. The distribution evolves according to the geographic situation of the many conflicts and disasters.1 In 1990, PSF founded a nonprofit humanitarian medical pharmaceutical center; a quality control laboratory (physical chemistry control) with ISO 9002 approval was added in 1994. The center is now independent of PSF. The range of products provided by this center to missions included drugs (63%), medical materials (28%), and biologic materials (9%). PSF supplies its missions through international submissions and purchases its products from the medical pharmaceutical center; it also purchases products in countries where missions are held when the products meet European standards. The Mission in Bosnia-Herzegovina Bosnia-Herzegovina is a small country recognized by the international community since 1992. Before the breakup of the former Yugoslavia, Bosnia-Herzegovina accounted for more than 4.1 million inhabitants. The UN High Commissariat of Refugees (UNHCR) estimates that more than 1.5 million people have relocated since the end of the conflict, leaving a total population of 3 800 000.18 With the Dayton agreements, Bosnia-Herzegovina was regrouped into two political entities: the Croat-Muslim Federation and the Serbian Republic of Bosnia. Reconstruction of the country involves the reorganization of political and public institutions and, more importantly, the health and education sectors. General democratic elections were held in the Serbian Republic of Bosnia in June 1998 and elections in the Croat-Muslim Federation will take place in 1999. At the beginning of Sarajevo’s siege, PSF sent a team of three expatriate pharmacists to Bosnia-Herzegovina. The objective of the emergency phase (1992–1995) was to set up a massive supply program, implementing a distribution system based on existing health centers. The signing of the Dayton peace agreement and a progressive return to peace and stability marked the beginning of the postemergency phase (1995–1997). This phase pursued the previous objectives of establishing a distribution network and added on the implementation of logistic centers. PSF widened its involvement to include medical laboratory analysis, the production of medicines, and the disposal of expired medications sent during the conflict, as well as the implementation of a national center for quality control. Currently, the 114
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development phase’s (1998–1999) objective is to provide adequate support for the reorganization of pharmaceutical care and services by establishing pharmacy work groups and to open and maintain good ties with the international community and Bosnia-Herzegovina pharmacists in order to facilitate the reorganization of their pharmacy practice. PSF’s mission in Bosnia-Herzegovina is important within the organization because it represents 28.8% of PSF’s international expenses from 1992 to 1998. ECHO (94%), EUAM (
