1. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Cohort III International Pain Policy Fellows Bangladesh Opioid Availability Action Plan Madison, Wisconsin, USA 10 August 2012

2. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1: State the 3-5 problems that lead to inadequate patient access to opioid analgesics – Be as specific as you can Problem 1: Problem 2: Problem 3: Problem 4: Problem 5: Absence of palliative care policy and guideline Current Narcotics Law is a barrier to prescribing and accessing opioids Lack of health care professionals trained in pain relief and palliative care Absence of immediate release oral morphine

3. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Step 1 – Develop the Action Plan Section A: State the 3-5 problems that lead to inadequate patient access to opioid analgesics. Section B: State the objective(s) that would address the problem. (WHAT) Section C: List the action steps needed to achieve the objectives. (HOW) Section D: List those who have the authority/responsibility to take the necessary action. (WHO) Section E: Indicate an approximate timeline for completion of the action steps. (WHEN) Section F: State the assistance (technical, financial) that will be needed to achieve each objective. (HOW MUCH) Section G: Expected outputs, and how measured

4. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Medication Information Level 6. PATIENTS Level 1: International Narcotics Control Board Level 2: National Competent Authority Level 3. Importer/Manufacturers/Distributors Level 4. Hospitals/Pharmacies/Hospice/PC programs Level 5. Physicians/Pharmacists/Other Drug Distribution System Model

5. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Action Plan for: BANGLADESH Prepared by: Dr.Rumana Dowla Dr.Farzana Khan Dr. Eric Krakauer Marty Skemp Brown 10 August 2012

6. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care A: PROBLEM 1 Absence of palliative care policy and guidelines

7. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Pain relief and palliative care policy approved by MoHFP that guides implementation of, and promotes access to, pain relief and palliative care nationwide. 2.National pain relief and palliative care clinical guidelines approved by MoHFP. B: State the objective(s) that would address the problem. Which objectives are the top priorities? (What?)

8. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care C: What action steps are needed to achieve the objectives? (How?) 1.Ask MoHFP to convene ad hoc committee to create: a)National pain relief and palliative policy (concise) b) National pain relief and palliative care clnical guidelines 2. Convene National Pain Relief & PC Policy Committee 2.Draft National Pain Relief & Palliative Care Policy 3.Draft National Pain Relief and Palliative Care Clinical Guidelines 4.Obtain approval from MoHFP for the two documents. 1.Minister of Health 2.Secretary of Health 3.Director General of Narcotics 4.Director General of Drug Administration 5.Prof. Nezamuddin Ahmad 6.IPPF Mentors 7.IPPF Fellows 8.MoHFP ad hoc pain relief and palliative care committee. 9.WHO representative D: List those who have the authority and/or responsibility to take the necessary action; and with whom they should collaborate. (Who?)

9. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care E: Timeline for completion of action steps. (When?)

10. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1. Funds for per diem: TA (travel allowance) and DA (daily allowance) 2. Funds for refreshment 3. Palliative care technical assistance from mentors and other IPPF staff 4. Funds for picking up and taking home ad hoc committee members 5. Funds for overseas travel for mentors F: What assistance (technical, financial) will be needed to achieve each objective under part “B”? (How much?)

11. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Approved National Pain Relief and Palliative Care Policy 2.Approved National Pain Relief And Palliative Care Clinical Guideline 3.Electronics copy of the above documents on DGHS (Director General Health Services) website G: Expected outputs, and how measured

12. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care A: PROBLEM 2 Current Narcotics Law is a barrier to prescribing and accessing opioids

13. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Amend or clarify Narcotics Law so as to establish balanced system for certifying physicians by Dept of Narcotics Control (NCA) to prescribe A-class and B-class narcotics for medical and scientific use. 2.Enable DNC certification of adequate number of trained physicians to make opioid analgesia universally accessible to patients in need in Bangladesh. 3.Revise incorrect or misleading items in Narcotics Control Law of 1990 that may create barriers to accessibility of opioids for medical or scientific use (items 5e, 7 – 1, 13 – 1). B: State the objective(s) that would address the problem. Which objectives are the top priorities? (What?)

14. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care C: What action steps are needed to achieve the objectives? (How?) 1.Draft proposal for DNC certification of physicians to prescribe A-class and B-class narcotic medicines Note: Physicians who have completed a basic training course (at least 6 days) in pain relief and palliative care from a training centre recognized by the MoH (or an equivalent training as determined by the director of an MoH-approved course) and passed the MoH examination in basic pain relief and palliative care will receive certification endorsed by the Ministry of Health AND separate narcotics prescribing certification from the Director General of Narcotics (as per amendment of item 13 1 of Narcotics Act of 1990). Each MoH-approved training center would submit to the MoH each year a list of physician who had passed the examination.. 2. Meet with the following to discuss the easiest method for amending (or clarifying) item 13.1 (and other items) of the Narcotics Act 1990 and, if appropriate, to discuss our draft proposal. a) Prof.Modasser Ali b) DG Narcotics c) Minister of Home Affairs (Police) d) Prof.Arup Ratan Chowdhury 3.Pursue process of change agreed upon in the above discussions.

15. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Home Minister 2.Minister of Health 3.Health Secretary MOHFP 4.Director General of Narcotics 5.Director General of Drug Administration 6.Prof. Nezamuddin Ahmad 7.IPPF Mentors 8.IPPF Fellows 9.MoH ad hoc pain relief and palliative care committee. 10.WHO representative D: List those who have the authority and/or responsibility to take the necessary action; and with whom they should collaborate. (Who?)

16. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care E: Timeline for completion of action steps. (When?)

17. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Per diem for government officials involved in discussing amending or clarifying the Narcotics Law when appropriate according to government regulations 2.IPPF staff and mentors F: What assistance (technical, financial) will be needed to achieve each objective under part “B”? (How much?)

18. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Revised item 13 1 (and items 5e, 7 – 1, 13 – 1) of Narcotics Control Act of 1990 2.Approved, rational, and balanced method for certifying physicians to prescribe A- class and B-class narcotics for medical or scientific use. 3.MoH approved basic and advanced training curriculum in pain relief and palliative care that includes training on diversion and dependence syndrome and addresses problem of impaired physicians (see Problem 3 below). G: Expected outputs, and how measured

19. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care A: Lack of trained health care professionals in pain relief and palliative care. PROBLEM 3

20. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care MoH approved basic and advanced curricula in pain relief and palliative medicine based on WHO (and MoH) guidelines. MoH approved basic and advanced courses in pain relief and palliative care held at least twice a year somewhere in the country. MoH approved basic and advanced courses in pain relief and palliative care offered in each state within three year. At least one trained pain relief and palliative care trainer (trained by BSMMU TOT curriculum) in each of the six divisions (like states) within three years. B: State the objective(s) that would address the problem. Which objectives are the top priorities? (What?)

21. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care C: What action steps are needed to achieve the objectives? (How?) Draft basic and advanced curricula in pain relief and palliative care based on existing curricula (BSMMU, Harvard / Vietnam MoH) Identify physicians from each of the six divisions to receive at least basic training (6 days) in pain relief and palliative care. Identify at least one physician from each division who are committed to devoting at least part of their careers to teaching and practicing pain relief and palliative care to receive TOT training in pain relief and palliative care. Prepare list of physicians whom we would like to receive training in pain relief and palliative care form all divisions. Send request to appropriate authority (probably Divisional Health Service, Divisional Medical Colleges, or hospital directors) to grant permission to these physicians to receive training in pain relief and palliative care. Establish schedule within two years for holding basic palliative care course twice per year and advanced course once per year. Note :Development of TOT training curricula and initial TOT trainings to be funded by existing University Grants Commission (UGC) grant.

22. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Minister of Health 2.Health Secretary of Ministry of Health 3.Vice Chancellor,BSMMU 4.Director of Divisional Medical Colleges 5.Medical Directors of Private Hospitals 6.Prof. Nezamuddin Ahmad 7.IPPF mentors 8.IPPF Fellows D: List those who have the authority and/or responsibility to take the necessary action; and with whom they should collaborate. (Who?)

23. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care E: Timeline for completion of action steps. (When?)

24. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.TA from IPPF Mentors. 2.Approval from Secretary of Ministry of Health 3.Approval from Hon. Minister of Health 4.Approval of training candidates by directors of Divisional Medical Colleges and directors of private hospitals. F: What assistance (technical, financial) will be needed to achieve each objective under part “B”? (How much?)

25. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1. Basic and advanced curricula in pain relief and palliative medicine. 2. Approval by Minister of Health of basic and advanced curricula in pain relief and palliative medicine. 3. List of physicians interested in pain relief and palliative care from each of the divisional medical colleges. 4.Two courses in basic palliative care and one course in advanced palliative care taught. 5. One TOT trained trainer in pain and palliative care from each divisional medical college. G: Expected outputs, and how measured

26. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care A: PROBLEM 4 Absence of immediate release morphine

27. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1.Immediate release oral morphine accessible to Bangladeshi patients in need as per Essential Medicine List of Bangladesh MoHFP 2008. B: State the objective(s) that would address the problem. Which objectives are the top priorities? (What?)

28. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care C: What action steps are needed to achieve the objectives? (How?) Plan A 1. Identify Bangladeshi pharmaceutical companies (at least two) willing to manufacture immediate release oral morphine. 2. Clarify how many, if any, Bangladeshi pharmaceutical companies have registered immediate release oral morphine. 3. If necessary, assist at least two Bangladeshi pharmaceutical companies to register immediate release oral morphine. 4.Persuade at least one Bangladeshi pharmaceutical company to start manufacturing IR oral morphine before August 2014. Plan B 1. Begin planning to import IR oral morphine from Nepal or India (Cipla.) 2. Get import license

29. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Director General of Drug Administration 2. Director General of Department of Narcotics Control 3. Managing Directors and Chief Operating Officers of pharmaceutical companies 4. Dr. Bishnu Paudal 5. IPPF mentors 6. Prof. Nezamuddin Ahmad (Chief of Dept of PC at BSMMU) 7. IPPF Fellows D: List those who have the authority and/or responsibility to take the necessary action; and with whom they should collaborate. (Who?)

30. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care E: Timeline for completion of action steps. (When?)

31. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care 1. Approval from Director General of Drug Administration 2. Approval from Director General of Department of Narcotics Control 3. IPPF mentors 4. Prof. Nezamuddin Ahmad (Chief, Dept of PC, BSMMU) 5. IPPF Fellows 6. Funds for arranging seminars with representatives of pharmaceutical companies. F: What assistance (technical, financial) will be needed to achieve each objective under part “B”? (How much?)

32. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Immediate release oral morphine available and accessible for pain relief and palliative care in Bangladesh. G: Expected outputs, and how measured