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Country Report for: The Kyrgyz Republic Team Members: Taalaigul Sabyrbekova, MD

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.

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Country Report for: The Kyrgyz Republic Team Members: Taalaigul Sabyrbekova, MD

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  1. 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

  2. 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

  3. General information Birth rate: 26,8 on 1000 Averageage: 24.7years 65 yearsandolder: 5,8% Total mortality: 6,6 на 1000 нас. Lifeexpectancy : 69.3 years male: 65.3 female: 73.64

  4. Age structure

  5. Mortality rate 2011

  6. Annual number of cancer cases 1. Cancer pain and palliative care The cancer cases grew 3.85% between 2010 and 2008. The rate between 2009 and 2008 is 2.94%.

  7. Cancer Detection by stages in 2010

  8. Cancer Mortality Cancer Mortality

  9. 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

  10. New cases of HIV in 2000-2009

  11. National AIDS policy • 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

  12. 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

  13. Lackofhealthcarefinancing (GDP 3,7) Braindrain, lackofmedicalworkers Weakmaterial-technicalbaseofhealthinstitutions Thereareareasofhealth, remainingoutsideofthereforms - oncology, psychiatry, TB Imperfectionofthesystemofcontinuingeducationandtrainingmedicalworkers Thehighpriceofdrugs(absence of the state regulation of prices ) Imperfectsystemofprimaryhealthcare Main issues in health care system in KG

  14. 2 hospices for HIV/AIDS patients Opioids are always available in specialized hospitals (oncology centers). National Oncology Center PC Department (25 beds) Morphine is allowed to prescribe to patients with cancer on 4th stage only In other cases, doctors prescribe Tramadol. Inter oblast Oncology Center PC Department Pharmacy 10 days 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 FMC Diploma of a physician or feldsher.

  15. 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 +

  16. Opioid Accessibility

  17. The cost of medications and health insurance coverage Health Insurance Fund covers cost of medicines by two ways: • Additional Package – for all insured people according to the list of medicines • 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: • Ketoprophen – 36000 mg or 360 vials • Promedol – 4800 mg or 240 vials • Morphine – 3000 mg or 300 vials

  18. Department of Medicines Supply and Medical Equipment of the Ministry of HealthRegistration Pharmacy Warehouse Storage State Agency for Drug Control Get approval and include to the Register List Pharmaceutical Distribution Company Pharmacy Hospital (Oncology Center) Customs Customs Clearance Health Insurance Fund Copayment Medical Practitioner Prescription Patient • 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

  19. 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

  20. Positive steps Working group on PC under the MoH Union for palliative care Mandatory healthinsurancefoundhasbudgetfor opioidsby State Guarantee Program Politicalsupport – MoH, MHIF, Parliamentmembers 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

  21. 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

  22. Problems Atleast 18 000 patientsneed PCannually No comprehensive educationalPC programs for physicians, medicalstudents No PC standards, clinical protocols Nooralmorphineinthecountry No developed mechanisms of financing of PC activities No home care multidisciplinaryPC modelsandhospices for all patients needed PC

  23. 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

  24. 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

  25. 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.

  26. Awareness raising and Advocacy campain“Life without pain”

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