Transcript Kyrgystan - Pain & Policy Studies Group

International Pain Policy Fellowship, Cohort III
Country Report for:
The Kyrgyz Republic
Team Members:
Taalaigul Sabyrbekova, MD
Aziz Abylgaziev, State Agency for Drug Control specialist
Roza Djakypova, MD Chief specialist of Ministry of Health
Madison, Wisconsin
6-10 August 2012
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Kyrgyz Republic
Area 199.900 km2
Population 5.4 million
Almost 70% of territory are
high mountainous and hardto-reach regions
Almost 70% - rural
population,
80% of them are poor
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
General information
• Birth rate:
26,8 on 1000
• Average age :
years
• 65 years and older:
24.7
5,8%
• Total mortality: 6,6 на 1000
нас.
• Life expectancy : 69.3 years
• male:
65.3
• female: 73.64
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Age structure
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Mortality rate 2011
Externally
caused death
10,9
Other
8,3
Some
infections and
Parasitic
diseases
2,5
Cancer
9,0
18
Perinetal
conditions
5,8
Digestive
organs
diseases
6,8
Respiratory
diseases
7,9
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Heart diseases
48,8
1. Cancer pain and palliative care
Annual number of cancer cases
The cancer cases grew 3.85% between 2010 and 2008.
The rate between 2009 and 2008 is 2.94%.
20354
20178
19600
2008
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
2009
2010
Cancer morbidity
14
12
10
2008
8
2009
6
2010
4
2
0
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Cancer Detection by stages
in 2010
Stage
Number
Percentage
I-II
1555
35,8
III
1804
41,5
IV
983
4345
22,7
IV
22,7%
I-II
35,8%
III
41,5%
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Cancer Mortality
12
10
2008
8
2009
6
2010
4
2
0
Esophagus
Stomac
Lung
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Breast
Cervical
Colon
Rectum
Prostate
Skin
1. HIV/AIDS pain and palliative care
Registered HIV/AIDS for June 1, 2012:
HIV: 4247 (male - 2909; female – 1153)
AIDS: 476
Died: 600; 211 of them due to AIDS
No information about pain
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
New cases of HIV in 2000-2009
671
532
388
233
133
146
2
3
125
153
165
5
6
4
1
4
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
7
8
9
10
National AIDS policy
1.
2.
3.
4.
Republic Unit “AIDS” established in June 6,1989 for prevention of
HIV
National Plan on HIV AIDS epidemic and its social and economic
impacts prevention for 2006-2010 (continued to the end of 2012).
Law No.149 “About HIV/AIDS in the Kyrgyz Republic” from August
13, 2005
Started 10th round of Global Fund Program on AIDS, TB and Malaria
in 2012
www.aids.gov.kg
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
The health care system in KR
• Budget for health care increased from 10 %
to 13 %
• Financial recourses were delivered from
oblast to national level
• Further development of primary health care
• Reforming of public health sphere
• Development of village health committees
• MoH strengthened main departments
• Developed M&E system
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Main issues in health care system in KG
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Lack of health care financing (GDP 3,7)
Brain drain, lack of medical workers
Weak material-technical base of health institutions
There are areas of health, remaining outside of the
reforms - oncology, psychiatry, TB
Imperfection of the system of continuing education
and training medical workers
The high price of drugs (absence of the state
regulation of prices )
Imperfect system of primary health care
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
2 hospices for HIV/AIDS patients
National Oncology Center PC
Department (25 beds)
Opioids are always available in
specialized hospitals (oncology
centers).
Morphine is allowed to prescribe to
patients with cancer on 4th
stage
only
In other cases, doctors prescribe
Tramadol.
10 days
Inter oblast Oncology Center PC
Department
Pharmacy
1. Morphine in 10 mg injection form.
2. Promedolum in 20 mg injection form.
Family
Medicine
Center
FMC
University of Wisconsin Pain & Policy StudiesFMC
Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Diploma of a physician or feldsher.
Maximum amount of:
Morphine for on prescription form - 20 vials
Tramadol
- 10 vials
International Narcotic Control Board
Has access to SADC data base
State Agency for Drug Control
Annually Estimate
For 2013 – April 2012
Ministry of Health
Statistics on controlled
drug usage annually
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Than chief nurse reports to
regional Health Department
Doctor reports to Chief Nurse
the list of prescriptions with
patient’s name
Opioid availability
WHO List
Codeine
Morphine injectable 10 mg
Morphine oral
immediate and sustained release
+
-
IAHPC List
Codeine
Fentanyl
Methadone
Morphine (immediate release)
Morphine (sustained release)
Oxycodone
Tramadol
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
+
+
+
Opioid Accessibility
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
The cost of medications and health insurance coverage
Health Insurance Fund covers cost of medicines by two ways:
1.
Additional Package – for all insured people according to the list of
medicines
2.
State Guaranty Program (SGP) – for 5 types of monitored diseases,
including cancer on 4th stage only
The cost of one vial of Morphine – 25,73 KGS (0.53 USD)
one vial of Promedol – 42,73 KGS (0.91 USD)
Reimbursement by Health Insurance Fund – 97%
Limits of SGP for cancer patients:
1.
Ketoprophen – 36000 mg or 360 vials
2.
Promedol – 4800 mg or 240 vials
3.
Morphine – 3000 mg or 300 vials
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Department of Medicines
Supply and Medical
Equipment of the Ministry
of Health Registration
Pharmaceutical
Distribution
Company
State Agency for Drug
Control
Pharmacy Warehouse
Pharmacy
Storage
Get approval and
include to the Register
List
Hospital (Oncology
Center)
Customs
Customs Clearance
Health Insurance Fund
Medical Practitioner
Copayment
Prescription
Barriers
•Special prescription form
•Four stamps and two signs
•Pharmacy dispense limit time (9:00 am – 4:30 pm)
•Limit on q-ty (20 vials of morphine)
•Limit time – prescription form works 10 days
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Patient
Positive steps
• PC included to the new National strategy of
reforming of health care system “Den - sooluk”
• PC included to the new National AIDS program
• PC included to the 4 laws on health care (Health
care, Cancer, HIV/AIDS, TB) - need Parliament approval
soon
• National strategy on PC developed
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Positive steps
• Working group on PC under the MoH
• Union for palliative care
• Mandatory health insurance found has budget for
opioids by State Guarantee Program
•Political support – MoH, MHIF, Parliament members
•
National Cancer Program is going to be launched
for the years of 2013-2018. Palliative Care will be
included in a working plan of National Cancer
Program. Availability of opioid analgesics is not
addressed, but this will be considered
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
National PC Program: main characteristics
and features
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Improve legislation base on PC
Establish PC individual service providing on all levels
Scale up public health role in development and
realization of PC programs
Include PC into post graduate education of
physicians
Define mechanisms and methods of PC financing
Establish PC patients register
M&E
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Problems
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At least 18 000 patients need PC annually
No comprehensive educational PC programs for
physicians, medical students
No PC standards, clinical protocols
No oral morphine in the country
No developed mechanisms of financing of PC
activities
No home care multidisciplinary PC models and
hospices for all patients needed PC
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Next steps
• Implement EPEC Curriculum to Kyrgyz State
Medical Academy, Kyrgyz State Medical
Institute for Continuing Education, Medical
colleges
• Develop clinical protocols, standards for PC
• Begin basic PC course in KSMI
• Involve Ministry of Social Protection on
education on PC of existing social workers
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Next steps
• 2 pilot projects on home based palliative
care, in Bishkek and Osh on the base of
Cancer centers
• Provide technical support for existing 2
hospices for patients with AIDS centers in
Bishkek and Osh
• To include PC in new National Cancer, TB
programs and identify sources of funding
• Improve access to oral morphine and opioids
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Palliative Care Union
Established in 2011
Members of the Union:
• Kyrgys State Medical Institute for Continuing Education
• Kyrgyz State Medical Academy
• National Oncology Center
• Republic Center for prevention of AIDS
• National TB Center
• Public Foundation “Ergene”
• Public Foundation “Sante”
• Breast Cancer Patient’s School
• Public Association of breast cancer patients
• Public Foundation “Voice of freedom”
• Public Foundation “Moltur-Koz”
However, none of these organizations provide palliative care at the
moment.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Awareness raising and Advocacy campain
“Life without pain”
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care