By Rob Darracott
You may have seen the pictures on social media and in the press of the pharmacist who suffered serious facial injuries during the bombing of Kharkiv, the city close to the Russian border with Ukraine. The vital work pharmacists do in conflict areas can occupy a lot of Catherine Duggan’s time. “In many places, much as during the Covid pandemic, the only places that are available for Ukrainian people are the pharmacy and their grocery store,” she says. “And those two things, plus the soldiers making sure they are open. It does take effort, but that's part of our job.”
Catherine says that while FIP has no mandate to do anything until asked, the All Ukrainian Chamber of Pharmacists requested help with supplies and funding of medicines. “We set about identifying other organisations who would be helping so we would be efficient,” she says. “As PGEU [who represent pharmacy at the EU level] were helping with the EU supplies of medicines, we said we would work with the other European countries where we have membership or who got in touch with us - we don't close our doors just because they're not a member. We've opened a donation site as well – our Japanese colleagues have donated more than €20,000 today. We’ve also got a Foundation, like a charity, so we make sure that it's able to help.
“Then we tell stories. Our Ukrainian colleagues are telling us what medicines they are particularly short of. Finnish colleagues got into some lorries that were going to the border and made sure there were medicines in there. Our colleagues from Yemen sent us an official letter to say ‘we can’t do much, but we’re going to train 10 Yemeni pharmacists and pay for them to go to Ukraine’. As a CEO, you’re supposed to be hard-nosed, looking at the bottom line, but my goodness... This is what I call solidarity. They’re going through their own crises, you know? It’s: ‘if I’ve got one coat, I’ll give you my coat. It makes you speechless.
“I'll give you another example that was right in the middle of Covid – the blast in Beirut in Lebanon in August 2020. We held an anniversary event last year, one year on in 2021, and the pharmacists were in bits, because the government have not replenished the medicines supplies. People are blaming the pharmacists because they can't get their parents cancer drugs. This has had a huge impact on our profession there. The Order of Lebanese Pharmacists asked for a fundraiser, because all the pharmacies were razed to the ground.
“Just think about that for a second - there's no pharmacies. It’s like that saying ‘you never miss the shelter of the hedge till it’s gone. Pharmacies in the community store medicines that people might need, as well as the ones they do need. Then they’re gone. All that investment… it was traumatic. People need a hug and we couldn’t do that because everything was virtual.
“We respond to what we're asked to, and we also respond in non-war situations, like natural disasters that happen – fires, floods, tsunamis and, and, and… It’s incredibly sobering. And we probably don’t do enough for the long term wars.” I ask about Afghanistan.
“We had to respond to our member organisation, the Afghanistan Nationwide Pharmacists Association, about medicine supplies. With a lot of the people leaving the country, there were major crises of supplies there, and we'd also be working with the countries where they go to see if we can arrange some kind of supplies system for them, if they're identifiable. The problem was that was so hastily done, and shambolically-led; I feel like we didn't step up as well as we could have done with better co-ordination, but I don't think we're alone in that given how it all unfolded.”
Partnerships at work
The Fédération Internationale Pharmaceutique (FIP) – French was the language of diplomacy when the organisation was founded in 1912 – is a non-governmental, not for profit organisation. It’s a federation of members and other organisations from around the world, based in The Hague in the Netherlands (the Dutch Society of Pharmacy proposed the formation of an international organisation, though international pharmacy congresses had taken place every few years from 1865).
FIP has had official relations with the World Health Organization since the inception of that body in 1948, working through a series of triennial agreements; WHO and FIP signed a Memorandum of Understanding in 2019. As such, FIP aligns with a number of United Nations functions in terms of health and education, representing pharmacists, pharmacy educators, pharmaceutical scientists, and it has pharmacy technician members too.
We respond to what we're asked to, and we also respond in non-war situations, like natural disasters
FIP was the first professional organisation to enter into a formal partnership with UNESCO (the United Nations Educational, Scientific and Cultural Organisation). The result, in 2010, was a unique global programme, entitled the University Twinning and Networking (UNITWIN) Global Pharmacy Education Development (GPhEd) Network, which has University College London’s School of Pharmacy as its host institution. The programme was the first in the field of higher education for any health profession and the first for global pharmaceutical education.
“UNITWIN is a response to workforce and capacity building,” Catherine says. “Do we have enough pharmacists around the world? If you haven't got pharmacy schools, then you are dependent on migration from other countries. The UNITWIN programme was set up to encourage countries that had curricula and academic capacity to share and showcase with Africa.” The first decade worth of work was captured in the FIP UNITWIN Pathfinder Toolkit, published last year.
“Now we’re setting up regional centres. Africa was the big focus 12 years ago, but other countries and regions have got their own problems. We’re signing up to a new decade of work with UNESCO this year. And we also have our FIPWiSE initiative – FIP Women in Science and Education, which aims to champion and enable women in pharmaceutical sciences and pharmacy education to achieve their fullest potential – which fits very much with UNESCO.
As of the end of March, FIP had 146 national member organisations, 173 academic institutional members, 22 observer organisations and 4,063 individual members. Through membership, FIP has a presence in 153 countries and territories covering 7.4 billion people and representing around 4 million pharmacists, pharmaceutical scientists and pharmacy educators.
“We did a very different World Pharmacists’ Day [September 25, commemorating the day FIP was set up in 1912] last year,” Catherine says. “We got pharmacists from each country to take part, so we’ve now got a map of where we have a presence and where we haven’t. We’re going to be working with those pharmacists – if they have a member organisation that will be welcome in FIP. If they don’t, can we help them with that? We've done that in some countries.
“Do they have a university? Do they have a regulator? Countries and regions can be very different around all of this. We’ve got so many countries that are fully developed in terms of having a professional regulator and bodies that can support good standards of practice and education and assessment. Could they share some of those experiences with the countries that are further behind? That’s a real mantra of FIP. We provide a platform for member organisations, but that platform can also be about partnerships, the provision of learning, knowledge and experiences, even training.”
Global solidarity sits at the heart of FIP. “If you take something as basic as the standards of medicine production and the incidence of substandard and falsified medicines, it's not just a problem for Africa or for South East Asia. It's not even a problem for, say, just Lithuania. We all are at risk from this. If you address problems from a global perspective, perhaps look at regionality, and then match country case studies with the countries that have got the big problems, global solidarity really helps.
“So much of what we would take for granted as good practice in these areas, other countries haven’t got sight of. If the high-income countries are not part of that story, we're missing huge experiences to draw from. Those experiences have to be the shining light. The stories of the journeys are important too. Some things have taken 20 or 25 years to establish in high-income countries, but other nations can run with them faster if they have toolkits and the knowledge.”
That does not mean that somewhere like the UK has nothing to learn. “We all have,” Catherine says. “Look at the WHO’s Astana declaration on primary health care – that was one of the first things I attended when I started at FIP in 2018. It was looking at the primary healthcare over the last 40 years. We’ve done great things, even in that short period of time, in maternal health and child health. But if you look at what we're dying of now, the UK is up there in terms of risk factors. Obesity, cardiovascular disease, non-communicable diseases (NCDs); we punch above our weight, and not in a good way. You can get some inspiration looking at other countries, those that do a lot with a little.”
We build on the strengths, the legacy, the history of everyone who's gone before.
That visit to Astana, the then capital of Khazakstan, made a big impression on FIP four woman delegation. “We got inspired; we signed pharmacy up to the declaration.” Catherine says what happened is illustrative of how FIP works. “Remember that White Paper Building on Strengths – that’s such a good title. We build on the strengths, the legacy, the history of everyone who's gone before.
“Around 2016, the human resources for health part of WHO warned that by 2030 there was going to be an 18 million shortfall in health workers. Pharmacy’s response through FIP’s education director was to say ‘we need some goals for this’. That aligned with the UNITWIN programme and 13 pharmaceutical workforce development goals, describing elements of workforce from academic capacity to curriculum design through to competencies, and equity and diversity in gender, were launched in Nanjing in 2016.
“So we went to Astana in 2018, signed pharmacy up, and in doing so got thinking that we needed to then set ourselves goals for 2030. We're not a mandated organisation; we've got no permissions or authorities to tell people what to do. But we took what was great about the pharmaceutical workforce development goals, and we built on each of them, but with science and practice added in.”
FIP’s 21 development goals (below) to “transform global pharmacy”, each with separate workforce, practice and science elements, were launched on 21 September 2020. “Those goals were a direct result of WHO at Astana asking ‘where is the pharmacy workforce’?” Catherine says. She picks out sustainability, access to medicines and services and equity as key. “Sustainability is our 21st goal, and that's includes sustainability of the workforce,” she says. That means understanding what pharmacists do and knowing how much they should be paid. “There's nothing worse than starting a project and it not being funded. It's better not to start it at all in my view. It's not ethical.
FIP Development Goal 17 Antimicrobial stewardship (detail)
Globally, we will:
- Have strategies and systems in place to develop a pharmaceutical workforce prepared to deliver quality services for antimicrobial stewardship (workforce element)
- Have infrastructures and frameworks in place to deliver services for antimicrobial stewardship (practice element)
- Promote research and development of new antimicrobials, new antimicrobial combinations and new techniques, and evaluate the impact of antibiotic stewardship programmes (science element)
“Everybody should have access to safe, affordable, effective medicines globally. And equity, which we expanded to include age, socio economic status, geography, gender, everything Covid has just opened our eyes to. Mix those three together, no one could argue with your vision for the world.”
Next steps for the organisation is a summit for health ministers, which will now be held in 2023, where evidence of impact against the goals that pharmacy delivers in primary health care. “We will present evidence of impact against the goals that pharmacy deliver in primary health care,” Catherine says. “We’ve bundled up NCDs, patient safety and prevention, from self-care through to immunisation. We’ll be talking about the co-morbidities pharmacists are presented with daily. We've got our global pharmaceutical observatory where we collect evidence to create case studies to showcase what country A does versus country B. It’s hard to be a prophet in your own backyard but, for example, Italy has turned 180 degrees and all pharmacists can become vaccinators, not just of Covid and flu, because they looked at, for example France. Of course, we have to then track the rest of the goals to 2030 but we're taking two and three-year chunks.”
Inside the organisation
The shaping of the goals, each with an element of workforce, practice and science, have also been a uniting force for the organisation itself. FIP’s Council is comprised of its member organisations, both national and scientific. Meeting in session “looks a bit like the UN with all the flags”.
Governance of the organisation is vested in its Bureau, which has delegated responsibility from the Council. It comprises 14 elected members including the president, who serves a four year term, plus the CEO. Former RPS president Ash Soni is a vice-president; the president, Dominique Jordan from Switzerland, is in the middle of his term of office. A smaller executive committee, comprising the president, scientific and professional secretaries and the FIP Education chair, proposes and coordinates activities and refers matters to the Bureau.
FIP has three Boards covering science, practice and education. The Board of Pharmaceutical Science celebrated its 50th birthday in 2020. FIP started with practice; the Board of Pharmaceutical Practice was 50 in 2015. FIP Education was formally constituted in 2020; links to academic institutional members and academic pharmacists sits in this area.
Sections, sitting under the Board of Pharmaceutical Practice, cover communities of practice - community, hospital, clinical biology, military and emergency, industry and so on. There are Commissions - on antimicrobial resistance and one that oversees the work of the observatory - and FIP-wide Forums covering technology and regulation. “The FIP Regulator Forum is really useful; regulatory bodies can come and advise and work through problems with like-minded people. And since regulators shouldn't join an advocacy bodies, they don’t have to be members to participate.”
As the FIP development goals were built on those for workforce development goals, FIP's workforce development hub is now being expanded FIP-wide to cover the 21 goals. “Projects are initiated in the hub, or the hub is used for advice and connecting people together who want to work on academic capacity or patient-centred care, for example.”
people were reaching across the table in tears to just touch each other's fingers, they’d never met a colleague from their neighbouring country
The final piece of the organisational jigsaw is FIP’s regional forums, which map onto WHO’s regions. “We work regionally with all our member organisations as well as separately; it's much easier for FIP to understand the global priorities from a regional perspective, rather than trying to force things top down.” And FIP has a relationship with the International Pharmacy Students Federation (IPSF), which like most national student bodies is independent of its ‘parent’, but there is a close link with FIP’s own very active Young Pharmacists Group.
FIP therefore comprises a series of linked and overlapping networks; for someone with an idea there’s probably a home for it somewhere where they can meet up with like-minded people, wherever in the world they are? “We can constitute working groups on particular areas, for example, recently there was something on sports medicine, which was important for the Olympics last year. Now we're thinking, where does that fit afterwards? Think of FIP as a house. We want to make it so you can have a room for your own specialist group, but it's got to have open plan areas where people can come together or huddle about a particular interest. You'd be amazed to see how much comes organically from the grassroots.”
Small team, big team
For an organisation with global reach, FIP is small; Catherine says she has fewer people in her team now than she had when she was a director at the RPS. Staff number around two dozen full time equivalents – 15 of whom are pharmacists. As many international organisations do, FIP supplements its staff by hosting internships which provide capacity and which offer real insight and development for individuals which might be utilised later by pharmacy somewhere in the world.
“We've been able to grow the team during the pandemic, because we've been delivering a lot digitally – events, roundtables, purposeful policymaking and publications,” Catherine says. “We have a team that get paid to do the job, but we've got this amazing bank of about 3000 volunteers. Three hundred of them are directly involved in the Boards and so on, but they bring colleagues in, and they get ‘infected’.” Volunteers can dip in and out; there is no specific time commitment, all are welcome.
“In 2020, everybody was firefighting. I know we did. We pivoted the whole business, suddenly, we’d done 130 digital events. We were never off the air. Last year, we took a more purposeful approach by talking to the members, getting them familiar with the goals and finding out what their needs and priorities were, to match them up or support them with project X, Y or Z. Or we might go into our archives and show them a publication, get them to do a case study to build on that.”
Everything is a little bit more accessible and a bit cheaper for everybody. Suddenly you can create some magic
That reconnection with members has also provided data on delivery of FIP’s goals. “A bit of progress on a goal in a region is fine,” Catherine says. “Not everything has to be dialled up to 11. As pharmacists, we’re obsessed by being precise, but sometimes if you have a cheesy little tagline, it unites everybody, from Jakarta to Japan, they get it.”
That can mean very long days, especially given work across timezones all over the world. “There’s always events going on, maybe interviews or podcasts as well as the grunt work of signing things off and making things happen,” says Catherine. “I've got a very high performing team who probably need more encouragement than management. They do sometimes let perfection get in the way of good, because they are so passionate about it. Our productivity is through the roof without all the travelling; now it’s going to be the art of balancing a bit more travel with the workload.”
“It’s stories that we want,” Catherine says. “One of our team members is Marwan El Akel, a young man, father of two girls, from Lebanon. in 2019 he set up vaccinations in refugee camps. He initiated it, learned from lots of different countries how you might do it without having the legal framework, and he did it. There’s a pharmacist with humanity on their sleeve. We recognised his work with an FIP Fellowship Award.
“I am super proud that behind the scenes of our conference in Seoul in 2017, South Korean colleagues had been really keen to engage their North Korean colleagues. We did quite a lot of work, but we were guessing at how it was going to go down. In 2019, North Korea sent the delegation, and we had a meeting – North Korean colleagues and South Korean colleagues. I'm not joking, people were reaching across the table in tears to just touch each other's fingers, they’d never met a colleague from their neighbouring country. That really moved me. That's something the Federation can do very well.
“We had a session on equity in that same Congress. It was really well-facilitated and people stood up and started telling stories. And we had some of the great and the good in our profession, from different countries, some quite reserved people, talking about people they are proud of, some got very moved during their personal reflections. These are the things that get me very engaged. I think you have to if you’re in a global organisation. Look at some of the amazing work of colleagues in places of much less wealth and structure. To be a CEO of a Federation like this in your own profession. It doesn't get much better than this really.”
FIP’s big set piece engagement, so fundamental it is enshrined in the organisation’s statutes, is its annual World Congress of Pharmacy and Pharmaceutical Sciences, which takes place in a different country each year. The Congress will return in Seville in Spain in 2022 after a two year pandemic hiatus – previously only world wars have prevented it.
Congresses are full on spectacular events. First timers can expect a warm welcome, Catherine says. “Let's say you’re a young pharmacist or a student, then you'll have a peer who will meet you and find out what you're interested in. We can even do a bit of cherry-picking if you need it. We have section and specialist area dinners and we’ve moved them much earlier in the week as we wanted to get people who were new to go to them and encourage experienced attendees to buddy up with a newbie.
“This year, we’re limiting the number of parallel events as we get back to the new normal, so that we have a much more ‘one FIP’ approach. We don't just want the scientists to go to one session and educators to go to another, we want people to experience the solidarity of being together. And with our goals having the three elements it makes sense.
“There’s a lot of socialising that goes on, there’s a big exhibition and there's a lot of networking opportunities. Our volunteers will use it as an opportunity to hold a dinner with friends that they've been working with for two years or three years.
I’ll get on with making sure that we've got our plans delivered...and getting this health minister summit under our belts
Catherine has a story from that first regional conference in Amman that illustrates the value of events. “It was half day, day, half a day, with a closing ceremony around lunchtime. At that point, our Palestinian colleagues arrived. They had been travelling the whole time, been pushed back on the borders. Our Jordanian friends put them up in the posh hotel, and ran all the videos of the Congress from the opening to the closing as a special piece.”
Difficulties with visas, affordability, as well as a reflection that signing the Astana declaration in 2018 might require the development of regional roadmaps for delivery, had led Catherine to experiment with regional conferences, the first in Amman in Jordan, the second in Ankara, Turkey, just before the pandemic. “We were planning in 2020 to go to Southeast Asia, to Indonesia and Ghana in Africa. That was the plan. Half a day, followed by a full day, with a big commitment at the end. Everything is a little bit more accessible and a bit cheaper for everybody. Suddenly you can create some magic. It's amazing. Then the pandemic hit and everything went online, which actually provided even more access for our colleagues.”
Regional congresses will be back, Catherine promises, with more reasons for holding them. “Some people aren't vaccinated enough to be able to come to Europe or to go to America,” she says, while open to all digital events over the past few years have given people access to issues and taken down some of the boundaries that existed to face to face meetings, but which can now be built upon. “People socialised through our digital events. They got to know each other. We might have been discussing the resilience and mental health of patients and the public, but then it became about families and friends and the other people on the line. Everybody has the same size space on screen - it was a case of equity in engagement.
That digital provision will remain, however. “We all need a bit more face to face now, but if we turned that off now, I think we'd be doing our lower income countries a disservice. We’d be doing four events a week and the numbers have not dropped – we don’t see the same people every week, but we see the same kinds of numbers for the same kinds of events. And if FIP is about access and equity, we try to practice what we're preaching.”
For now, she is looking forward to Seville and an extended World Pharmacy Week to celebrate pharmacy in all its aspects, science, practice, technicians. “Hopefully we will be in attendance at the World Health Assembly in May, and have a high level meeting with Dr Tedros to showcase the progress we've made against the Astana declaration. “I’ll leave my presidents and vice-presidents to do the handshaking and visiting if they're able to, and I’ll get on with making sure that we've got our plans delivered, our publications produced and getting this health minister summit under our belts.”
Change in real time
As Dr Duggan is speaking, you get a sense that change is happening in real time, and that’s what excites her. “When I see a country that doesn't have much, accelerate an issue that has taken us in the UK 25 years to get our head around, or we've overcomplicated it beyond belief and they just do it - there is something amazing about that.
“You see youngsters leading initiatives. We've got a guy called Israel Bimpe from Rwanda, who is unbelievable in his entrepreneurial approach. He’s now a director for [research group] GTM Africa, using drones to supply medicines to places that cannot get them, with safety checks, all appropriate. He is a super member of our Young Pharmacists Group. What he’s doing now is nothing to do with FIP, in that we didn’t initiate it, but one thing FIP can do is give people like him a megaphone. That’s what I love.
While it was recently announced that the Royal Pharmaceutical Society, one of the founder members in 1912, had left FIP, UK pharmacists can still get involved. “We’ve got lots of individual members,” Catherine says, “and the Academy of Pharmaceutical Sciences is a member organisation, let’s not forget them, they are very active within FIP, so we do have a UK organisation, but individual members are welcome to sign up.
“The UK has got the most amazing profile in FIP. Because of the heritage of UK pharmacy, being at the forefront alongside for example, Australia and the US, there is a respect. But what you’re seeing with the commodification of medicines, the stack them high, sell them cheap, is a deprofessionalising of the profession. That’s a risk and a lot of other countries are seeing that and then tackling things differently.
“If you look at the problems a pharmacist in the UK faces, they’re not that different to any one else globally. Professionally, we all want a higher status, so what can we do about that? Well, here's some goals, here’s some evidence of impact. Why don't you show us what impact you've made? And then we'll see if a minister will listen to you.
“Or you could come to a World Health Assembly with us and go and talk to your own health minister. When I first started it was Jeremy Hunt. It was good to be able to say ‘hi, I’m here from FIP, but did you know, blah, blah, blah, advocate for the UK. When you look at things from another perspective, you can get some comfort, but you might also get some solutions you haven't thought of.
“We've got to live our professional lives for a long time. A nice meeting where you can share ideas and hear about success goes a long way.”