University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 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 International Pain Policy Fellowship, Cohort III Madison, Wisconsin 6-10 August 2012

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Area km 2 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 Kyrgyz Republic Kyrgyz Republic

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 1000Birth rate: 26,8 on 1000 Average age : 24.7 yearsAverage age : 24.7 years 65 years and older: 5,8%65 years and older: 5,8% Total mortality: 6,6 на 1000 нас.Total mortality: 6,6 на 1000 нас. Life expectancy : 69.3 yearsLife expectancy : 69.3 years male: 65.3male: 65.3 female: 73.64female: 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

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Annual number of cancer cases The cancer cases grew 3.85% between 2010 and The rate between 2009 and 2008 is 2.94%. 1. Cancer pain and palliative care

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 StageNumberPercentage I-II155535,8 III180441,5 IV ,7 Cancer Detection by stages in 2010

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

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Registered HIV/AIDS for June 1, 2012: HIV: 4247 (male ; female – 1153) AIDS: 476 Died: 600; 211 of them due to AIDS No information about pain 1. HIV/AIDS pain and palliative care

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

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 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 (continued to the end of 2012). 3.Law No.149 “About HIV/AIDS in the Kyrgyz Republic” from August 13, Started 10 th round of Global Fund Program on AIDS, TB and Malaria in National AIDS policy

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 %Budget for health care increased from 10 % to 13 % Financial recourses were delivered from oblast to national levelFinancial 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 Lack of health care financing (GDP 3,7)Lack of health care financing (GDP 3,7) Brain drain, lack of medical workersBrain drain, lack of medical workers Weak material-technical base of health institutionsWeak material-technical base of health institutions There are areas of health, remaining outside of the reforms - oncology, psychiatry, TBThere are areas of health, remaining outside of the reforms - oncology, psychiatry, TB Imperfection of the system of continuing education and training medical workersImperfection of the system of continuing education and training medical workers The high price of drugs (absence of the state regulation of prices )The high price of drugs (absence of the state regulation of prices ) Imperfect system of primary health careImperfect system of primary health care Main issues in health care system in KG

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care National Oncology Center PC Department (25 beds) Inter oblast Oncology Center PC Department Family Medicine Center FMC Pharmacy 1. Morphine in 10 mg injection form. 2. Promedolum in 20 mg injection form. Opioids are always available in specialized hospitals (oncology centers). Diploma of a physician or feldsher. Maximum amount of: Morphine for on prescription form - 20 vials Tramadol - 10 vials 10 days Morphine is allowed to prescribe to patients with cancer on 4 th stage only In other cases, doctors prescribe Tramadol. 2 hospices for HIV/AIDS patients

University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Ministry of Health Statistics on controlled drug usage annually Than chief nurse reports to regional Health Department Doctor reports to Chief Nurse the list of prescriptions with patient’s name State Agency for Drug Control Annually EstimateFor 2013 – April 2012 International Narcotic Control Board Has access to SADC data base

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 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 4 th 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 – mg or 360 vials 2.Promedol – 4800 mg or 240 vials 3.Morphine – 3000 mg or 300 vials The cost of medications and health insurance coverage

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 Pharmacy Warehouse Storage Pharmacy Medical Practitioner Prescription Patient Health Insurance Fund Copayment Pharmaceutical Distribution Company Department of Medicines Supply and Medical Equipment of the Ministry of Health Registration State Agency for Drug Control Get approval and include to the Register List Customs Customs Clearance Hospital (Oncology Center) 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 Positive steps PC included to the new National strategy of reforming of health care system “Den - sooluk”PC included to the new National strategy of reforming of health care system “Den - sooluk” PC included to the new National AIDS programPC 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 soonPC included to the 4 laws on health care ( Health care, Cancer, HIV/AIDS, TB) - need Parliament approval soon National strategy on PC developedNational 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 Working group on PC under the MoH Union for palliative care Union for palliative care Mandatory health insurance found has budget for Mandatory health insurance found has budget for opioids by State Guarantee Program opioids by State Guarantee Program Political support – MoH, MHIF, Parliament membersPolitical support – MoH, MHIF, Parliament members National Cancer Program is going to be launched for the years of Palliative Care will be included in a working plan of National Cancer Program. Availability of opioid analgesics is not addressed, but this will be consideredNational Cancer Program is going to be launched for the years of 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 patients need PC annuallyAt least patients need PC annually No comprehensive educational PC programs for physicians, medical studentsNo comprehensive educational PC programs for physicians, medical students No PC standards, clinical protocolsNo PC standards, clinical protocols No oral morphine in the countryNo oral morphine in the country No developed mechanisms of financing of PC activitiesNo developed mechanisms of financing of PC activities No home care multidisciplinary PC models and hospices for all patients needed PCNo 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 centers2 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 OshProvide 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 fundingTo include PC in new National Cancer, TB programs and identify sources of funding Improve access to oral morphine and opioidsImprove access to oral morphine and opioids

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

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”