The World Health Organi-zation opened the Office of the Special Representative of the Director-General (Dr. Gro Harlem Brundtland) in Moscow in December 1998. The first Special Representative was Dr.Harald Siem, who retired at the end of last May after a successful initial period of the programme.

Dr. Brundtland has nominated Dr. Mikko Vienonen as her new Special Representative after Dr.Siem. Dr. Vienonen comes from the WHO Regional Office for Europe in Copenhagen where he has worked for 6 years as Regional Adviser for Health Services Management.

Russia and Moscow are familiar places for him, as the collaboration with the Ministry of Health and different institutions has been frequent. Dr. M.Vienonen also knows many of the major actors in Russia on the donor side such as the World Bank and EU/TACIS. The terms of reference of the new WHO Office have been clarified and broadened beyond humanitarian assistance to include also health sector development projects. In short, this is what the Office and the Special Representative is expected to do:

• to consolidate WHO’s presence in Russia;

• to coordinate health assistance based on WHO’ technical capacity;

• to be responsible for technical support operations (financial and budgetary control);

• to work on strategies for assisting Russian health authorities in combating critical diseases such as TB, HIV/AIDS and structural issues linked to access to essential drugs;

• to represent DG in high-level meetings concerning humanitarian assistance and other health related matters;

• to liaise with and advise UN and other organizations, WHO Member States, financial institutions and other donors on health priorities and the delivery of humanitarian and other health related assistance;

• to initiate, support and facilitate formulation of biennial medium-term plan for the cooperation between WHO and the Russian Federation.

The current problems of drug supply in the Russian Federation are particularly severe in the programmes and institutions which depend on the federal budget. Funds are short for hospitals and the reimbursement system which has been in place for large segments of the population. The result has been that patients at large must pay for their own drugs, that drugs are less readily available, that there has been a substitution from expensive to less costly, in some cases less quality drugs, and in general a threat to the drug production and distribution capacity in Russia.

As poverty increases, the situation becomes worse. The drugs are available, but not affordable for many patients. Hospitals are running out of drugs for antibiotics, anaesthetics, gloves, needles and syringes, in particular in peripheral regions. Medical care is set back fifty years.

The situation calls for rethinking of drug policies and financing. WHO has warned against large scale donations of drugs. Donations will relieve the situation for a while, but at the same time undermine the capacity to produce and distribute drugs. The government policy now is to support the domestic industry as much as possible. Emphasis is on local actors.

At the same time, there is a need to reconsider which segments should be the beneficiaries of free medicine; currently not all the veterans, Chernobyl victims etc. are among the poorest. (More on this from recent paper in Duma.) But poverty in itself is so widespread in Russia, and it is difficult to find a practical indicator for poverty which could make it a useful criterion for direct assistance.