Improving Palliative Care at a Global Level

Kathleen M. Foley, MDKathleen M. Foley, MDPatient Advocacy MeetingPatient Advocacy Meeting

BudapestBudapestJune 29-30,2009 June 29-30,2009

2002 WHO Definition of 2002 WHO Definition of Palliative CarePalliative Care

"Palliative care is an approach which improves quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual"

Palliative Care as a Public Palliative Care as a Public Health IssueHealth Issue

affects all peopleaffects all people need for better information on need for better information on

end-of-life careend-of-life care potential to prevent sufferingpotential to prevent suffering potential to prevent diseasepotential to prevent disease

Palliative Care as a Palliative Care as a Prevention ModelPrevention Model

prevents needless sufferingprevents needless suffering provides peer educationprovides peer education provides patient centered careprovides patient centered care incorporates self-management incorporates self-management

programsprograms

The continuum of palliative The continuum of palliative carecare

Diagnosis Death

Therapies to modify disease(curative, restorative intent)

Actively Dying

BereavementCare

Life Closure

Therapies to relieve suffering, improve quality of life

6m

EducationEducation

ImplementationImplementation

DrugAvailability

DrugAvailability

WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel

PolicyPolicyPolicyPolicy

Context

Context

Outcomes

Outcomes

EducationEducation

ImplementationImplementation

DrugAvailabilit

y

DrugAvailabilit

y

WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel

PolicyPolicyPolicyPolicy

Context

Context

Outcomes

Outcomes

EducationEducation

ImplementationImplementation

DrugAvailability

DrugAvailability

WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel

PolicyPolicyPolicyPolicy

Context

Context

Outcomes

Outcomes

0

10

20

30

40

50

60

70

Denm

ark

Austri

a

Icela

nd

Franc

e

Norway

Sweden

Switzer

land

Luxe

mbo

urg

Unite

d Kin

gdom

Gibr

altar

Irelan

d

Belgiu

m

Nethe

rland

s

Ger

man

y

Spain

Slove

nia

Polan

d

Czech

Rep

ublic

Finlan

dIta

ly

Eston

ia

Hunga

ry

Bulga

ria

Slova

kiaM

alta

Lith

uani

a

Roman

ia

Latv

ia

Andor

ra

Croat

ia

Ukrai

ne

Yugos

lavia

Gre

ece

Belar

us

Alban

ia

Turke

y

Mac

edon

ia

Consumption of Morphine in Europe Consumption of Morphine in Europe mg/capita, 2001mg/capita, 2001

Source: International Narcotics Control Board; United Nations Demographic YearbookSource: International Narcotics Control Board; United Nations Demographic YearbookBy: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2004By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2004

Mg/capitaMg/capita

UkraineUkraine1.3 mg/capita1.3 mg/capita

Global meanGlobal mean5.4 mg/capita5.4 mg/capita

Sources: International Narcotics Control Sources: International Narcotics Control Board; United Nations population dataBoard; United Nations population dataBy: Pain & Policy Studies Group, By: Pain & Policy Studies Group, University of Wisconsin/WHO University of Wisconsin/WHO Collaborating Center, 2008Collaborating Center, 2008

2006 Global 2006 Global Consumption of Consumption of MorphineMorphine

0

20

40

60

80

100

120

140

160

154 Countries

Global mean, 5.9847 mgCOUNTRY Mg/capita

Albania 0.4644

Armenia 0.8187

Georgia 1.8200

Hungary 2.1643

Moldova 1.0331

Romania 0.0837

Serbia 0.1339

Ukraine 1.7845

HungaryHungary

MoldovaMoldova

AlbaniaAlbania RomaniaRomania

SerbiaSerbiaArmeniaArmenia

UkraineUkraine

GeorgiaGeorgia

Sources: International Narcotics Sources: International Narcotics Control Board; United Nations Control Board; United Nations population data By: Pain & Policy population data By: Pain & Policy Studies Group, University of Studies Group, University of Wisconsin/WHO Collaborating Center, Wisconsin/WHO Collaborating Center, 20082008

EURO Consumption of Morphine, EURO Consumption of Morphine, 20062006

0

20

40

60

80

100

120

140

160

180

Aust

ria

Denm

ark

Fran

ce

Portu

gal

Norw

ay

Switz

erlan

d

Icela

nd

Unite

d Kin

gdom Swed

en

Slove

nia

Slova

kia

Germ

any

Belg

ium

Gibr

altar

Irela

nd

Neth

erlan

ds

Luxe

mbou

rg

Bulga

ria

Czec

h Re

publi

c

Israe

l

Polan

d

Esto

nia

Spai

n

Finlan

d

Malta Italy

Lithu

ania

Ando

rra

Hung

ary

Cypr

us

Latvi

a

Geor

gia

Ukra

ine

Croa

tia

Rep.

of M

oldov

a

Arm

enia

Bela

rus

Gree

ce

Alban

ia

Russ

ian F

eder

ation

Azer

baija

n

Serb

ia

Uzbe

kistan

Kyrg

yzsta

n

Roma

nia

Turkm

enist

an

Mace

donia Turke

y

EURO mean, 12.5917 mg Global mean, 5.9847 mg

COUNTRY Mg/capita

Albania 0.4644

Armenia 0.8187

Georgia 1.8200

Hungary 2.1643

Moldova 1.0331

Romania 0.0837

Serbia 0.1339

Ukraine 1.7845

GeorgiaGeorgia

HungaryHungaryUkraineUkraine

MoldovaMoldova

AlbaniaAlbaniaRomaniRomaniaa

SerbiaSerbiaArmeniaArmenia

World Health Assembly Cancer Prevention and Control 58.22

25 May 2005

Urges member states to ensure the medical availability of opioid analgesics

Requests the WHO Director General (1) to explore mechanisms for funding cancer prevention, control and palliative-care, especially in developing countries.

(2) to examine with the International Narcotics Control Board how to facilitate the adequate treatment of pain using opioid analgesics.

INCB Annual Report for 2004

March 2005

““In view of the continued inadequate global In view of the continued inadequate global consumption of opiates for the treatment of consumption of opiates for the treatment of pain, the Board reiterates that it would pain, the Board reiterates that it would welcome a further increase in global demand welcome a further increase in global demand for opiates. The Board encourages for opiates. The Board encourages Governments to take steps to increase the Governments to take steps to increase the medical use of opiates in their countries in medical use of opiates in their countries in order to meet their real needs for the treatment order to meet their real needs for the treatment of pain.”of pain.”

WHO Access to Essential Medicines Program

Created an office for controlled Created an office for controlled substances as essential medicinessubstances as essential medicines

Appointed Willem Scholten as Appointed Willem Scholten as program directorprogram director

To develop a strategic plan with NGO To develop a strategic plan with NGO partnershipspartnerships

WHO Access to Essential Medicines

Program To focus on low and medium To focus on low and medium

resource countriesresource countries To support pain and palliative To support pain and palliative

care as a human rightcare as a human right

Publications on International Publications on International Palliative Care Issues Palliative Care Issues

Journal of Pain and Symptom Journal of Pain and Symptom Management Volume 33 ,Number 5 Management Volume 33 ,Number 5 May, 2007: Advancing Palliative Care: May, 2007: Advancing Palliative Care: The Public Health PerspectiveThe Public Health Perspective

Health Economics and Palliative care; Health Economics and Palliative care; What We Know and What We Need to What We Know and What We Need to Know. In press, 2008 Know. In press, 2008

World Cancer Declaration 2008World Cancer Declaration 2008

Outlines the critical steps needed to build the Outlines the critical steps needed to build the basis for sustainable delivery of effective basis for sustainable delivery of effective cancer prevention, early detection, treatment cancer prevention, early detection, treatment and palliative care worldwideand palliative care worldwide

World Cancer Summit, Geneva,2008World Cancer Summit, Geneva,2008

World Cancer Declaration World Cancer Declaration 20082008

Based on: Based on:

Article 25 of the Universal Declaration of Article 25 of the Universal Declaration of Human Rights declares that “everyone Human Rights declares that “everyone

has has the right to a standard of living, adequate the right to a standard of living, adequate for health and well being for himself and for health and well being for himself and

his his family, including medical care.”family, including medical care.”

7. 7. many more cancer patients in pain will have many more cancer patients in pain will have access to effective pain control measuresaccess to effective pain control measures

2020 Goals2020 Goals

7. the number of cancer patients with access to 7. the number of cancer patients with access to appropriate treatment, rehabilitation and palliative care appropriate treatment, rehabilitation and palliative care in adequately equipped treatment facilitiesin adequately equipped treatment facilities

9. the number of cancer patients in pain worldwide 9. the number of cancer patients in pain worldwide that have access to effective pain controlthat have access to effective pain control

Intermediate TargetsIntermediate Targets

3030

Strategies for the advancement of Palliative

Care as a Human Right

Submission to the committee ICESCRSubmission to the committee ICESCR Submission to the office of the Special Rapporteur Submission to the office of the Special Rapporteur

to the UN Human Rights Commission on the right to to the UN Human Rights Commission on the right to healthhealth

Promotion of an International Convention on PainPromotion of an International Convention on Pain Encourage human rights organizations to become Encourage human rights organizations to become

involved in advocacy for palliative careinvolved in advocacy for palliative care Use current declarations (Cape Town, Korea, Use current declarations (Cape Town, Korea,

Budapest) as advocacy tools with your governmentBudapest) as advocacy tools with your government

www.equalpartners.info

In this 47-page report Human Rights Watch said that countries could In this 47-page report Human Rights Watch said that countries could significantly improve access to pain medications by addressing the causes of significantly improve access to pain medications by addressing the causes of their poor availability. These often include the failure to put in place their poor availability. These often include the failure to put in place functioning supply and distribution systems; absence of government policies functioning supply and distribution systems; absence of government policies to ensure their availability; insufficient instruction for healthcare workers; to ensure their availability; insufficient instruction for healthcare workers; excessively strict drug-control regulations; and fear of legal sanctions among excessively strict drug-control regulations; and fear of legal sanctions among healthcare workers.healthcare workers.

Access to Pain Treatment as a Human Access to Pain Treatment as a Human RightRight

““Please , do not make us Please , do not make us suffer anymore…….”suffer anymore…….”

http://www.hrw.org/en/reports/2009/03/02/please-do-not-make-us-suffer-any-morehttp://www.hrw.org/en/reports/2009/03/02/please-do-not-make-us-suffer-any-more

  

            

                   

                  

                    

                        

                          

                                  

                  

               

  

Promoting Hospice & Palliative Care Worldwide

IAHPC 2006

Developed essential drug list for Developed essential drug list for palliative carepalliative care

Drafted WHO monograph on palliative Drafted WHO monograph on palliative carecare

Sponsors international faculty Sponsors international faculty scholars awardscholars award

Sponsored 2006 Venice Declaration o Sponsored 2006 Venice Declaration o the need for research in palliative the need for research in palliative care.care.

Joint Declaration and Statement Joint Declaration and Statement of Commitment: Palliative Care of Commitment: Palliative Care and Pain Treatment as Human and Pain Treatment as Human Rights Rights

Project coordinated by the IAHPC and Project coordinated by the IAHPC and WPCA sign on at WPCA sign on at www.hospicecare.comwww.hospicecare.com

IAHPC List of Essential IAHPC List of Essential MedicinesMedicines

34 medications are listed34 medications are listed 14 medications currently on the 14 medications currently on the

existing WHO Essential Listexisting WHO Essential List

IAHPC List of Essential IAHPC List of Essential MedicinesMedicines

Global Access to Pain Relief Global Access to Pain Relief InitiativeInitiative

Supported by International Union Supported by International Union Against Cancer (UICC)Against Cancer (UICC)

-global advocacy initiative-global advocacy initiative

-raise awareness for policy change-raise awareness for policy change

-focus on cancer patients-focus on cancer patients

Dr. Simbo Daisy Amanor-Boadu

Nigeria

Prof. Snežana Bošnjak

Serbia

Prof. Rosa Buitrago Republic of Panama

Mrs. Nguyen Thi Phuong Cham

Vietnam

Dr. Henry Dr. Henry DdunguDdungu

UgandaUganda

Dr. Jorge Dr. Jorge EisenchlasEisenchlas

ArgentinaArgentina

Dr. Marta Dr. Marta Ximena LeónXimena León

ColombiaColombia

Mr. Gabriel Mr. Gabriel MadiyeMadiye

Sierra LeoneSierra Leone

2006 International Pain Policy Fellowship

Pain & Policy Studies Group

University of Wisconsin

October, 2006 Madison, Wisconsin

Supported by the

Open Society Institute

To provide research-based information on palliative care in the global context

To disseminate this information through the Observatory website and through other means

To undertake primary research studies to generate such information

To support academic work in resource poor regions

To work in partnership with key organisations and individuals

IOELC Aims

Monitoring—Opioid Monitoring—Opioid ConsumptionConsumption

Grants FundedGrants Funded

The Romania ProjectThe Romania Project

WHO workshop in Budapest (2002)WHO workshop in Budapest (2002)(Bulgaria, Croatia, Hungary, Lithuania, Poland, Romania)(Bulgaria, Croatia, Hungary, Lithuania, Poland, Romania)

Prescribing severely restricted in RomaniaPrescribing severely restricted in Romania

–- - Complicated forms and authorizationsComplicated forms and authorizations

– Dose and time limits; no flexibilityDose and time limits; no flexibility

– For incurable cancer, not for HIV/AIDSFor incurable cancer, not for HIV/AIDS Many patients die before obtaining morphineMany patients die before obtaining morphine 35 year-old anti-narcotics law and regs35 year-old anti-narcotics law and regs Ministry of Health appointed a CommissionMinistry of Health appointed a Commission New statute sent to Parliament July 2005New statute sent to Parliament July 2005 New regulations to be finalized in 2006New regulations to be finalized in 2006

WHO Workshop,Budapest 2002

Change is possible if we work together

Progress in Europe

1.1. FranceFrance: : 7 days7 days 28 days28 days

2. 2. ItalyItaly: : 8 days8 days 1 month; 1 month; Rx simpl.Rx simpl.

3. 3. GermanyGermany: : 1 day1 day no limit no limit

4. 4. PolandPoland: : 100 mg100 mg 4.0 grams4.0 grams

5. 5. Romania:Romania: 3 days3 days 30 days30 days

Mongolia Pain Relief &Mongolia Pain Relief &Palliative Care InitiativePalliative Care InitiativeMongolia Pain Relief &Mongolia Pain Relief &

Palliative Care InitiativePalliative Care Initiative

MongolianMinistry of Health

MongolianPalliative Care

Society

WorldHealth Organization

Education . . . Education . . .

2001-5:2001-5: 400 doctors, 600 nurses 400 doctors, 600 nurses sensitized sensitized

(MPCS – Odontuya, OSI )(MPCS – Odontuya, OSI )

2004:2004: Established regional training center, Established regional training center, regular journal (MPCS – OSI )regular journal (MPCS – OSI )

2004: 2004: Palliative care recognized as medical Palliative care recognized as medical discipline (3 months CAQ )discipline (3 months CAQ )

2005:2005: State University of Ulaanbaater adds State University of Ulaanbaater adds palliative care to medical palliative care to medical

curriculumcurriculum

PolicyPolicy

2002:2002: Leadership conference - workgroupsLeadership conference - workgroups2004:2004: Follow-up conference – policies, Follow-up conference – policies,

Rx rules change – Palliative care Rx rules change – Palliative care included in national health planincluded in national health plan

2005:2005: Standards for palliative careStandards for palliative care2006-9:2006-9: National Health PolicyNational Health Policy Develop Develop

guidelines, train professionals, guidelines, train professionals, Establish MD Teams all aimags, districtsEstablish MD Teams all aimags, districts

2006+: 2006+: Develop National Cancer ControlDevelop National Cancer Control Policy Policy

Prescribing OpioidsPrescribing Opioids

2002: 2002: Only oncologists RxOnly oncologists Rx

10 tabs or amps per Rx per 3 10 tabs or amps per Rx per 3 daysdays

2005:2005: Any doctor can Rx, Any doctor can Rx,

Amount needed for 7 daysAmount needed for 7 days

ImplementationImplementation

2000:2000: NCC – 10 bed PCU (OSI )NCC – 10 bed PCU (OSI )

2002:2002: NCC – PCU NCC – PCU to 16 beds ( MOH ) to 16 beds ( MOH )

2002-present: 2002-present: 4 hospices in UB4 hospices in UB

2006:2006: 20 General Oncologist start20 General Oncologist start community palliative care networkcommunity palliative care network

around aimag and district around aimag and district hospitals hospitals

( each will have 2-5 PC beds( each will have 2-5 PC beds ) )

The Ocean Road Cancer Institute The Ocean Road Cancer Institute Palliative Care Centre, TanzaniaPalliative Care Centre, Tanzania

WHO Community Health Approach to Palliative Care for HIV and Cancer Patients in

Africa

Model Initiative in Providing Palliative Care

Uganda Ministry of Health included palliative care in its National Health Sector Strategic Plan

Uganda developed and funded an essential drug program and changed restrictive laws to allow oral morphine in home-based settings

Policy Initiative Policy Initiative ExamplesExamples

Hungarian ExperienceHungarian Experience– IPCI sponsored Policy Conference resulted IPCI sponsored Policy Conference resulted

in Hungarian Health Insurance Fund in Hungarian Health Insurance Fund sponsoring a pilot program to develop six sponsoring a pilot program to develop six model palliative care programsmodel palliative care programs

– Palliative care has been included in the Palliative care has been included in the National Cancer Control ProgramNational Cancer Control Program

– The MOH has committed to develop The MOH has committed to develop palliative care services in all regions in palliative care services in all regions in the country by 2010the country by 2010

Not-for-profit, non-governmental organizationNot-for-profit, non-governmental organization Founded 1998 by International Union against Cancer Founded 1998 by International Union against Cancer

(UICC) & Institut Pasteur, Brussels(UICC) & Institut Pasteur, Brussels National Cancer Institute (NCI) assists by providing National Cancer Institute (NCI) assists by providing

financial, technical & intellectual support financial, technical & intellectual support Located at Institut Pasteur, BrusselsLocated at Institut Pasteur, Brussels Branches in USA, France, Egypt & NepalBranches in USA, France, Egypt & Nepal Offices in UK, Brazil, India & Tanzania Offices in UK, Brazil, India & Tanzania

ADVANCING PALLIATIVE CARE INTERNATIONALLY

World Health OrganizationGeneva - WHO Cancer Unit Europe – WHO Aging Program

UN AIDS Global Fund for TB, Malaria & AIDS PEPFAR European Union European Parliament Council of Europe

ADVANCING PALLIATIVE CARE INTERNATIONALLY (NGO’s)

International Association of Hospice and Palliative Care

Help the Hospices OSI’s International Palliative Care Initiative National Hospice and Palliative Care

Organization

ADVANCING PALLIATIVE CAREINTERNATIONALLY (NGO’S)

International Psycho-oncology Society (IPOS)

European Federation of IASP Chapters (EFIC)

European Society of Medical Oncology (ESMO)