Kyrgystan - World Health Organization; 2000. _Available at by wangnianwu

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									  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 hard-
      to-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 :            24.7
                                                        years

                                                      • 65 years and older:     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                                       Some
                caused death                                  infections and
                    10,9                              Other      Parasitic
                                                       8,3       diseases
                                                                    2,5          Cancer
                                                                                  9,0
                Perinetal
               conditions
                   5,8
 18




                     Digestive                  Respiratory                    Heart diseases
                      organs                     diseases                          48,8
                     diseases                       7,9
                        6,8

University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
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                               2009               2010

University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
                                                           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        IV
                                                                   22,7%
          III                        1804                41,5                   I-II
          IV                         983                 22,7                  35,8%
                                     4345




                                                                         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             Breast   Cervical   Colon   Rectum   Prostate   Skin

     University of Wisconsin Pain & Policy Studies Group
     World Health Organization Collaborating Center for
     Pain Policy and Palliative Care
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

                               146                    153   165
               133                              125


 4

  1               2               3               4    5     6     7     8     9    10
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
                                              National AIDS policy


1.          Republic Unit “AIDS” established in June 6,1989 for prevention of
            HIV
2.          National Plan on HIV AIDS epidemic and its social and economic
            impacts prevention for 2006-2010 (continued to the end of 2012).
3.          Law No.149 “About HIV/AIDS in the Kyrgyz Republic” from August
            13, 2005
4.          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


•          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

                                                 Opioids are always available in
                                                 specialized hospitals (oncology
   National Oncology Center PC                   centers).
        Department (25 beds)
                                                       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                                                        Pharmacy
         Department




                                                              1. Morphine in 10 mg injection form.
                                                              2. Promedolum in 20 mg injection form.
                      Family
                      Medicine
                      Center                                      Maximum amount of:
                                                                  Morphine for on prescription form - 20 vials
                                                                  Tramadol                          - 10 vials
                                FMC




        University of Wisconsin Pain & Policy Studies FMC
                                                      Group
        World Health Organization Collaborating Center for
Diploma of a physician or feldsher.
        Pain Policy and Palliative Care
                                  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             Than chief nurse reports to   Doctor reports to Chief Nurse
                                                        regional Health Department    the list of prescriptions with
                    drug usage annually                                                       patient’s name




University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
                                 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




                                           State Agency for Drug            Pharmacy Warehouse
    Pharmaceutical                                Control                                                         Pharmacy
     Distribution                                                                  Storage
      Company                                 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                                Patient

   University of Wisconsin Pain & Policy Studies Group
   World Health Organization Collaborating Center for
   Pain Policy and Palliative Care
                                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

•       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

•   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

								
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