Kosovo after the conflict: rebuilding pharmaceutical services

Having been frequently in the news during 1999, Kosovo has now emerged from the most recent of the Balkan wars. In what was probably the largest forced movement of people in Europe since the 1939-45 war, more than half of Kosovo’s 1.8 million ethnic Albanians fled from their homes, mainly to neighbouring Albania and Macedonia. Following the Kosovo peace agreement, which requires the United Nations to provide interim civil administration, most of the refugees have now returned home. Delivery of health care services has been seriously disrupted, adding to the burden of neglect of the past 10 years when the Serbian government put few resources into Kosovo. During the 1990s, several health care centres were closed and most Albanian health care professionals lost their jobs. Even before the conflict there were shortages of drugs. A huge reconstruction effort is now under way. For a few days in November, 1999, Pamela Mason visited Kosovo’s main town, Pristina, to meet pharmacists who are helping to rebuild the region’s pharmaceutical services

It is a cold, damp Saturday afternoon, and a thin wind blows along the main street of Pristina. Winter is not far off. Military trucks belonging to the NATO-led international security force (Kfor) and a variety of international aid agency vans pass as I make my way to one of the town’s main pharmacies.

Inside the pharmacy, a cheerful pharmacist and an equally cheerful pharmacy technician, both dressed in white coats, are dispensing medicines to a small queue of patients. The service appears efficient and professional, in spite of the fact that dusk is fast approaching and the only light is provided by a couple of candles. There has been no water supply all day.

Power cuts are a frequent occurrence. The United Nations Mission in Kosovo (UNMIK), the region’s interim government, is making an effort to get Kosovo’s electricity supply back to normal for the winter but, owing to years of neglect, the antiquated power stations are taking some time to repair.

Moreover, the pharmacy has been forced to move from its previous position a few hundred yards down the street. Situated under the telecommunications building, which was bombed by NATO during the conflict, the original pharmacy was destroyed, but medicines were retrieved and moved to the new location. On the day of my visit the range and quantity of stock appears limited, but not inadequate. Most of the patients seem to be getting their prescriptions filled.

Yet life is far from normal. Kosovo has no banks, no income tax and no currency of its own. When pharmacists in the primary care “state” sector are paid – and many are still waiting for their money – it will be in German marks because that is the official currency.

Moreover, all the familiar problems with drug donations – out of date stock and half used, unlabelled boxes – have emerged. The number of non-governmental organisations (NGOs) working in Kosovo has escalated to more than 300, and many are turning up with medicines. Desire to respond to the situation and at the same time raise the profile of their organisations means that action often overrides good practice. And, unfortunately, this creates havoc, not to mention a lot of work in disposing of the unwanted drugs.

So, how is pharmacy coping six months after the signing of the peace agreement? Dr Paul Spivey and Mr Martin Auton, both UK pharmacists, have been working as pharmaceutical consultants for the World Health Organisation in Pristina. After the end of the conflict, one of the first jobs was to assess the pharmaceutical needs, Dr Spivey says. This meant looking at the availability of and access to essential drugs, reviewing the situation regarding drug donations and developing a strategy for the restructuring of pharmaceutical services.

Drug supply

During his early post-conflict visits to hospital pharmacies, state pharmacies and private pharmacies, Dr Spivey found that the availability of essential drugs was not nearly so bad as he had expected. However, the situation would have got worse once existing stocks had been used because there was no formal mechanism for replacing stock and no money to buy it. Moreover, UNMIK Health, the de facto Ministry of Health for Kosovo, has a policy to provide free health care using external funding, and money therefore had to be found for drugs.

A figure of $11m was estimated to be needed to supply drugs to both the primary and secondary care sector for a period of six months, and Mr Auton worked on gaining commitment to provide this sum from a variety of different agencies and donors.

The European Community Humanitarian Office (ECHO) agreed to fund Pharmaciens Sans Frontieres (PSF) to supply drugs both to the primary health care sector and Pristina hospital, initially for a period of three to four months. External funding will undoubtedly be needed (and will probably be provided by ECHO) for much longer, possibly until a system, albeit health insurance, tax or co-payment by patients, is established to fund drugs and other health care costs. Pilot co-payment projects are already being set up in some areas, but a sustainable system for funding health care is probably some way off yet.

Ms Sophia Logez, a pharmacist from Lille in northern France, is managing the drug distribution for PSF, and, understandably, she describes her work as an “awesome responsibility”. Having spent 18 months in Bosnia and one year in Kosovo, however, she is not without experience.

One of the greatest needs in terms of medication has not been antibiotics – which is what everyone expects – but shampoo and lotion for the treatment of lice and scabies, Ms Logez says. Pediculosis was a problem in the refugee camps in the summer and continues to be a problem in Kosovo itself. Unfortunately, many people bought organophosphates from agricultural establishments to treat themselves and their children, and as a result of this, three babies died during last summer.

Most drugs are still arriving in Kosovo by road, but with only one route, from Macedonia, that is open, safe and practical to use, trucks can face a delay of up to a week to cross the border. So, unless you are in a vehicle owned by the UN, NATO or one of the major aid agencies – in which case you are usually waved straight on – the quickest way to cross the border is to walk.

A queue of three to four hundred trucks is not unusual and it can take as long as two months from the time of ordering for drugs to reach the region. Indeed, a recent consignment of haemodialysis fluids arrived almost too late. Sent from Sweden to Skopje (the capital of Macedonia), the consignment was then held up in the queue at the Kosovan border. UK Kfor was asked to bring it in, but when they saw the size of the consignment they said no. The decision was then taken to hire a local driver with a truck to travel in convoy with a group of US Kfor vehicles. Unfortunately, some of the Kfor vehicles failed to realise that the truck was part of the convoy, so they overtook it and the truck was turned back at the border only to have to go right to the back of the queue again. However, the second time around, the same plan worked, and the haemodialysis fluids arrived just in time.

Drug distribution

Getting drugs into Kosovo is certainly a challenge, but so is ensuring that they reach the people who need them. Describing the state health care system that was in place before the conflict, Dr Spivey explained that primary care was provided through a network of “ambulantas”, usually staffed by one doctor and serving a population of approximately 2,000. There were also “health houses”, staffed by a number of doctors offering a range of specialties. Some of these establishments distributed drugs.

Secondary care was available in each of Kosovo’s six hospitals, including the central hospital in Pristina, which also provided tertiary care. Prescription medicines were dispensed free of charge either through the hospitals or the state pharmacies, of which there were about 50, and all medicines were supplied by a central state wholesaler.

The fact that the state health care system was organised by the Serbian administration meant that many Albanians were disinclined and sometimes frightened to use it. Moreover, closure of many health care facilities by the Serbian authorities led to more than 90 per cent of ethnic Albanian health professionals losing their jobs, and the majority of posts in the state health care system were held by Serbs.

At the end of the 1980s, Albanian health professionals set up a “parallel” system of health care in Kosovo, opening their own ambulantas, and about 120 small private pharmacies which were supplied by a number of NGOs and two private wholesalers. Mr Milaim Abdullahu, a senior Albanian pharmacist who remained in Pristina throughout the conflict, told me that he had owned a private pharmacy, but like many others this had been looted and burned by the Serbs.

A joint decision was taken by the WHO and PSF to distribute most of the drug supplies to the state pharmacies. This was because the state pharmacies rather than the private pharmacies appeared to be the most likely to provide a good professional service. Drugs are provided to the state pharmacies free of charge and the patients also obtain them free – just the same as before. In theory, therefore, no money changes hands in state pharmacies, and it was intriguing to see community pharmacies without tills. However, this situation will eventually change and state pharmacies will probably operate much like British ones with a mixture of public and private business.

According to Ms Logez, PSF is currently covering about 50 per cent of the population’s drug needs, although there have been complaints from both pharmacists and primary care doctors about a lack of such drugs as third generation cephalosporins. These were available through the state system in primary care before the conflict and there is an expectation that they should still be available. But needs are not the same as wants, Ms Logez explains.

Regulation

Kosovo currently has no law, and pharmacy is no exception to this. There is no regulatory system and almost anything goes. Mr Abdullahu says that several private pharmacies are being opened by individuals who are not pharmacists – lawyers, economists, recent high school graduates and so on. This is leading to huge profiteering from sales of drugs, including narcotics and sedatives, with no control, and worse still, tragic dispensing errors, such as amitriptyline being given instead of Amoxil and aspirin instead of aminophylline, to name just two. The WHO has recently prepared a document for pharmacy regulation, and Mr Abdullahu emphasises that he will be “very happy when UNMIK has approved it”.

Prescribing

Rational drug use has not so far been an issue in Kosovo, and there are instances, for example, of hypertension being treated with a mixture of methyldopa and diazepam. There is therefore an enormous education job to do with health care professionals.

Meanwhile, doctors continue to prescribe as they have always done, and because private pharmacies carry a wide range of stock obtained from private wholesalers, patients can obtain their supplies easily, but they have to pay for them. In one private pharmacy I visited, there was quite a variety of injections, including digoxin, neostigmine, frusemide, benzylpenicillin and third generation cephalosporins as well as a range of transfusion products. The use of injections is high in this part of the world, simply because patients believe in the value of a medical intervention that is visible.

Hospital pharmacy

PSF is also supplying drugs to the main hospital in Kosovo, which is in Pristina, and other agencies and organisations are supplying the other five hospitals. After the crisis, almost all Serb staff, particularly those in management positions, left the hospitals, and Albanian staff took their place. Some Albanians were returning to positions they had held 10 years ago, but those who had worked only in the “parallel system”, which provided primary but not secondary health care, had no experience of work in a hospital.

UNMIK has introduced international management teams in each of the six hospitals in Kosovo to work with local healthcare workers. Pristina hospital, which I visited, is currently being run by a British team led by Professor Anthony Redmond and funded largely by the UK Department for International Development (DFID). In mid June, when Professor Redmond first arrived, the hospital was in chaos, with wild dogs wandering about and bodies rotting in the mortuary.

Since then, progress has been nothing short of dramatic. A brand new emergency room was fitted out in six weeks, but as Dr Michael Rolfe (director of the hospital’s department of internal medicine) says, the Claire Short (Secretary of State for International Development) coming to open it focused the mind wonderfully. Ms Joanna Greenfield, a British nurse who is running the new centre is slowly, but successfully, encouraging local nurses to adopt the practice of nurse triage; in other words, a nurse, rather than a doctor, decides where the patient should be treated. The problem of establishing new practice is not necessarily one of training – although that is needed, she says – but of changing attitudes of health care workers and patients who are used to seeing doctors as the only point of care.

The hospital pharmacy is also experiencing enormous change. The man who is now chief pharmacist, Mr Adnan Mustafa, explained that after the conflict drugs were scattered round the stores in half opened boxes and liquid medicines were leaking on to the floor. The first job was therefore to collect all the medicines from the various hospital clinics and conduct an inventory. This completed, the team of four pharmacists and 10 technicians started to restore order out of chaos and shelves were obtained on which to store the medicines.

By the end of 1999 the pharmacy was to be relocated, and in the middle of November I was amazed to see a huge empty, unfitted area – including a former underground nuclear bunker – which was planned to house the pharmacy by the end of December. I suspect many hospital pharmacists would envy such progress.

Education and training

The higher education system in Kosovo collapsed 10 years ago. More than one third of the 2,500 doctors were trained in the “parallel system” and it is not clear what their qualifications are. With pharmacists, however, the situation is slightly clearer. Until 1990, pharmacists trained in Belgrade but when they were no longer inclined to do that, they tended to go to universities such as Tirana in Albania, Sarajevo in Bosnia and Sofia in Bulgaria and they could therefore obtain a credible pharmacy qualification.

A pharmacy department opened in Pristina’s faculty of medicine for the first time in 1996. It offered a five-year programme, but has seen students only through the first three years. And because of the conflict, some students may have to repeat their third year. Moreover, the department is facing enormous problems in terms of lack of equipment, laboratories, reference books, and journals as well as limited teaching skills in some areas of the curriculum, notably clinical pharmacy.

The future

The war in Kosovo is over – at least on paper – but the future of the region remains uncertain and the conflict will have implications for physical, mental and emotional health for generations to come. During the four weeks after the signing of the peace agreement, an estimated 150 people were maimed or killed by explosions of mines in Kosovo. Years of disruption to health care services have resulted in poor management of chronic diseases such as diabetes, asthma, hypertension and heart failure. The full extent of mental disorders, including anxiety and depression, remains to assessed.

UNMIK and the international agencies will be in Kosovo for the foreseeable future and external funding for the pharmaceutical sector could well be needed for at least the next two years. External funding, of course, only provides a breathing space while sustainable systems are established. In relation to pharmaceutical services in Kosovo, this means establishing an internal drug supply system to take over when the aid agencies have gone. But how keen the pharmaceutical industry will be to open new manufacturing sites in a country of 2.2 million people remains to be seen. Equipment that was not looted from the only factory that used to make drugs in Kosovo is out of date, and it is not possible to operate that particular plant according to good manufacturing practice. New investment is clearly required.

The pharmaceutical service will need to be funded internally, whether by income tax, health insurance or patient co-payment or a mixture of all three. A strong regulatory system will be needed both to protect the public and to maintain the credibility of the profession. Verifying the qualifications of the present pharmacists and providing adequate training to update them also needs to be tackled. And the fledgling school of pharmacy requires help to put its five-year degree programme on a solid footing. Yes, there is plenty of work to be done, but the pharmacists I spoke to are already starting to make a difference.

ACKNOWLEDGMENT I should like to thank Mr Lirim Azizi (assistant to the World Health Organisation pharmaceuticals consultant) for his help as a translator during interviews with the various local people I visited in Pristina.