country report for: the kyrgyz republic team members: taalaigul sabyrbekova, md

University of Wisconsin Pain & Policy Studies GroupWorld Health Organization Collaborating Center forPain Policy and Palliative Care

Country Report for:

The Kyrgyz RepublicTeam 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


Area 199.900 kmArea 199.900 km22

Population 5.4 millionPopulation 5.4 million

Almost 70% of territory are Almost 70% of territory are high mountainous and hardhigh mountainous and hard--

toto--reach regionsreach regions

Almost 70% - rural Almost 70% - rural population,population,

80% of them are poor80% of them are poor

Kyrgyz RepublicKyrgyz Republic


General informationGeneral information

• Birth rateBirth rate: : 26,8 26,8 onon 1000 1000

• Average age Average age : : 24.724.7 years years

• 665 years and older: 5 years and older: 5,8% 5,8%

• Total mortalityTotal mortality: : 6,6 на 1000 6,6 на 1000 нас. нас.

• LLife expectancy : ife expectancy : 69.3 years 69.3 years

• male: male: 65.365.3

• female:female: 73.64 73.64


Age structureAge structure


Mortality rate 2011Mortality rate 2011


Annual number of cancer cases The cancer cases grew 3.85% between 2010 and 2008. The rate between 2009 and 2008 is 2.94%.

1. Cancer pain and palliative care


Stage Number Percentage

I-II 1555 35,8III 1804 41,5IV 983

434522,7

Cancer Detection by stages in 2010


Cancer Mortality Cancer Mortality


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

1. HIV/AIDS pain and palliative care


New cases of HIV in 2000-2009


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

National AIDS policy

http://www.aids.gov.kg/


The health care system in KRThe health care system in KR

• Budget for health care increased from 10 % Budget for health care increased from 10 % to 13 % to 13 %

• Financial recourses were delivered from Financial recourses were delivered from oblast to national leveloblast 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


• Lack of health care financingLack of health care financing (GDP 3,7) (GDP 3,7)• Brain drainBrain drain, l, lack of medical workersack 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 There are areas of health, remaining outside of the

reforms - oncology, psychiatry, reforms - oncology, psychiatry, TBTB• Imperfection of the system of continuing education Imperfection of the system of continuing education

and training medical workersand training medical workers• The high price of drugsThe high price of drugs ((absence of the state absence of the state

regulation of prices regulation of prices ))• Imperfect system of primary health careImperfect system of primary health care

Main issues in health care system in KG


National Oncology Center PC Department (25 beds)

Inter oblast Oncology Center PC Department

Family Medicine Center

FMC

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 4th stage

onlyIn other cases, doctors prescribe

Tramadol.

2 hospices for HIV/AIDS patients2 hospices for HIV/AIDS patients


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 +


Opioid Accessibility


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

The cost of medications and health insurance coverage


Pharmacy Warehouse

StoragePharmacy

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


Positive stepsPositive steps

• PC included to the new National strategy of PC included to the new National strategy of reforming of health care system “Den - sooluk”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 (PC included to the 4 laws on health care (Health Health

care, Cancer, HIV/AIDS, TB) - care, Cancer, HIV/AIDS, TB) - need Parliament approval need Parliament approval soon soon

• National strategy on PC developed National strategy on PC developed


Positive stepsPositive steps

• Working group on PC under the MoHWorking group on PC under the MoH• Union for palliative careUnion for palliative care• Mandatory healthMandatory health insurance found insurance found has has budget for budget for opioidsopioids by State Guarantee Program by State Guarantee Program•Political support – MoHPolitical support – MoH, MHIF, P, MHIF, Parliament membersarliament members

•National Cancer Program is going to be launched for National Cancer Program is going to be launched for the years of 2013-2018. Palliative Care will be included the years of 2013-2018. Palliative Care will be included in a working plan of National Cancer Program. in a working plan of National Cancer Program. Availability of opioid analgesics is not addressed, but Availability of opioid analgesics is not addressed, but this will be consideredthis will be considered


National PC Program: main characteristics National PC Program: main characteristics and featuresand 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


ProblemsProblems

• At least 18 000 patients need PAt least 18 000 patients need PCC annually annually• No comprehensive educationalNo comprehensive educational PC PC programsprograms for for

physicians, physicians, medical students medical students • No PC No PC standardsstandards, clinical , clinical protocols protocols • No oral morphine in the country No oral morphine in the country • No developed mechanisms of financing of PC No developed mechanisms of financing of PC

activitiesactivities

• No home care No home care multidisciplinary multidisciplinary PC modelsPC models and and hospices for all patients needed PChospices for all patients needed PC


Next stepsNext 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


Next stepsNext steps

• 2 pilot projects on home based palliative 2 pilot projects on home based palliative care, in Bishkek and Osh on the base of care, in Bishkek and Osh on the base of Cancer centers Cancer centers

• Provide technical support for existing 2 Provide technical support for existing 2 hospices for patients with AIDS centers in hospices for patients with AIDS centers in Bishkek and OshBishkek and Osh

• To include PC in new National Cancer, TB To include PC in new National Cancer, TB programs and identify sources of fundingprograms and identify sources of funding

• Improve access to oral morphine and opioidsImprove access to oral morphine and opioids


Established in 2011Members 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


Awareness raising and Advocacy campain“Life without pain”

country report for: the kyrgyz republic team members: taalaigul sabyrbekova, md

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