Cohort III
International Pain Policy Fellows
Opioid Availability Action
Planning Worksheet
Madison, Wisconsin, USA
6 – 10 August 2012
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Action Plan - Sri Lanka
Dr.Suraj Perera
Dr. N. Jeyakumaran
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
10 August 2012
Provinces (9) & Districts(25) of Sri Lanka
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Sri Lanka
Nine Provinces.
Nine Cancer Units
Types of Hospitals
•
•
•
•
•
•
Teaching Hospitals
Provincial General Hospitals
District General hospitals
Base Hospitals
Divisional Hospitals.
Central Dispensaries.
National Cancer Control Programme, Sri Lanka
National Advisory
Committee on
Cancer Control
Minister of Health
Secretary of Health
Director General of Health Services (DGHS)
Deputy Director General (DDG/ PHS 1)
Director / National Cancer Control Programme
* Consultant Community Physician
National Health Council
Ministry of Health
National Advisory Committee on Cancer Control
National Cancer
Control
Programme
(NCCP )
National
Cancer
Institute
(Maharagama)
Technical working Groups
1. Cervical / Breast Cancer
Prevention
2. Oral Cancer prevention
2. Diagnosis & Cancer Therapy
3. Palliative care
4. Cancer surveillance
5. Cancer research
Provincial Cancer
Treatment Centres
( Kandy, Galle, Jaffna,
Anuradhapura, Badulla,
Batticaloa Ratnapura,
Kurunegala
Other National
level institutions
( FHB ,
Epidemiology
Unit , D/NCD)
Provincial
Ministries of
Health
Provincial Committees of Cancer
Prevention & Control
( PDHS, RDHS,Line Ministry Health
Institutions of the district.,
Consultant Oncologist at provincial
cancer treatment centres , Curative &
Preventive health sectors )
District Committees of Cancer
Prevention & Control
Issue
Inadequate Patient
access to Opioid
Analgesics
Problems
• Less Priority given to Palliative Care
• Limitations of existing law related to Opioids
prescription
• Inconsistencies on Distribution & Availability
of Opioids at the point of delivery
• Gaps in knowledge, attitudes and practices of
health care professionals on pain
management in palliative setting
Problem 1:
Less Priority given to Palliative Care
• Underlying reasons for the problem .
– Multiple health issues with communicable & non
communicable diseases.
– About 15,000 to 20, 000 new cancer cases / year.
– Most of the cancers are detected in late stages.
– Palliative care is given a less priority.
– Some aspects of palliative care.
• In Cancer treatment centres.
• In four hospices.
– With few facilities.
– minimum human resources.
Problem 1 :
Less Priority given to Palliative Care
Objective (What)
To consider palliative care as a priority in the Cancer
Policy of Sri Lanka
Action steps (How)
To include the component of palliative care in the
National Cancer control Policy.
Authority and/or
Responsibility (Who)
• Secretary/Health
• National Advisory Committee on Cancer Control
• National Cancer Control Programme .
Timeline (When)
September 2012
Assistance
(How Much)
Expert participation Reviewing the Draft Policy
Document.
Expected outputs
Palliative Care is an essential component in the National
Cancer Control policy.
Output measurement
Relevant palliative care Policy statement.
Problem 1 : (Cont…)
Less priority given to Palliative Care
Objective(s) (What)
To coordinate planning, implementation and evaluation of
palliative care initiatives nationally
Action steps (How)
To establish a National Working Group on Palliative Care for
Cancer Patients
Authority and/or
Responsibility (Who)
National Advisory Committee on Cancer Control
Timeline (When)
September 2012 onwards
National Cancer Control Programme
At least two meetings in each year
Assistance
(How Much)
Technical advice on initiatives
Expected outputs
Palliative care initiatives are conducted in coordinated manner
Output measurement
Functional National Working Group on Palliative Care for Cancer
Patients established.
No. of meetings held per year, No. of Meeting Reports
Problem 1 : (Cont…)
Less priority given to Palliative Care
Objective(s) (What)
To conduct advocacy leading to acceptance of palliative care
as a priority
Action steps (How)
To conduct an advocacy meeting to obtain support from all
stakeholders
Authority and/or
Responsibility (Who)
National Advisory Committee on Cancer Control,
National Cancer Control Programme ‘
Sri Lanka Medical Association, Sri Lanka College of Oncologists/
Anethesiologists/ Family Medicine
WHO Country Office - Sri Lanka
Sri Lanka Cancer Society
Timeline (When)
Every year in the month of October, commencing from year
2012
Assistance
(How Much)
Logistic support for an International expert
Expected outputs
Participation of stakeholders to the advocacy meeting
Ability to get support from stakeholders
Output measurement
Report of advocacy meeting
Guest Lecture : Palliative Care
Symposium on Palliative Care – 2010
Symposium on Palliative Care – 2010
Problem 2 :
Limitations of existing law related to Opioids prescription
Underlying reasons for the problem
Deficiencies of POISONS,OPIUM, AND DANGEROUS DRUGS ordinance & its
Amendments
Under section 56 (1)
• “A medical practitioner may administer, prescribe or supply any dangerous drug for the
treatment of his patients, but shall not supply to any patient more than the amount to
be taken by him during three days.”
Under section 59 (2c)
• “The total amount of the drug prescribed shall not exceed the amount to be taken by
the patient during three days: Provided that the prescription may direct that the amount
prescribed may be supplied on more than one but not more than three occasions at
intervals to be specified in the prescription”
Problem 2 :
Limitations of existing law related to Opioids prescription
Objective (What)
To amend the existing law that restrict duration of opioid
prescription to the patients
Action steps (How)
Detailed review of existing legal documents (amendments,
regulations, administrative orders)
Identify the necessary amendments & submit to Legal
Draftsmen Department for further action
Cabinet Approval, Public Opinion, Parliamentary approval
Authority and/or
Responsibility (Who)
Ministry of Health
National Advisory Committee on Cancer Control
Legal Draftsmant Department
Timeline (When)
2012-2014
Assistance
(How Much)
Technical Assistance – Information related to similar
amendments in other countries
Expected outputs
Relevant law is amended
Output measurement
Availability of amended legal document
Problem 3:
Inconsistencies related to the distribution &
availability of opioids at the point of delivery
• Reasons for the problem..
– In Sri Lanka, palliative care and pain management
is mainly offered at cancer units.
– There is a varying level of availability of drugs and
practice of dispensing analgesics including opioids.
– Supply of Morphine: from one week to a month.
– An availability of minimal pain management without
access to Oral Morphine in the District General and
Base Hospital.
Problem 3:
Inconsistencies on Distribution & Availability of
Opioids at the point of delivery
Objective ( What)
To Identify the Reasons for the Inconsistencies
Action steps (How)
Reviewing the current problem at the Institutional level including Health
System Research in each Cancer Hospital. (BOAT Survey)
Authority and/or
Responsibility (Who)
National Advisory committee
National Cancer Control Programme.
Director, MSD
Directors of each Hospitals.
Oncologists.
Pharmacists.
IPP Fellows.
Timeline (When)
Till February 2013.
Assistance
(How Much)
1. Technical assistance for Research activities eg. Research papers /
Questionnaires / advise on methodology.
2. Study Materials / Books on Health System Research.
3. Support on Statistics
Expected outputs
Better understanding of the reasons for the problem.
Output measurement
Reports.
Problem 3: (Cont…)
Inconsistencies on Distribution & Availability of
Opioids at the point of delivery
Objective(s) (What) To ensure the availability of the opioids at the Teaching
Hospitals and Provincial General Hospital (9) level.
Action steps (How)
Conducting pilot studies to forecast the amount of
opioids in two cancer centres
Authority and/or
Responsibility
(Who)
Director, MSD
Directors of each Hospitals.
Oncologists.
Pharmacists.
Timeline (When)
September 2013
Assistance
(How Much)
Technical assistance.
Expected outputs
To see the estimates.
Output measurement
The reports of estimates.
Problem 3: (Cont…)
Inconsistencies on Distribution & Availability of
Opioids at the point of delivery
Objective(s) (What)
To make availability of opioids at the District General
Hospital(16) level.
Action steps (How)
Conducting pilot programmes in two District General Hospital.
Authority and/or
Responsibility
(Who)
National Cancer Control Programme.
Directors of each Hospitals.
Oncologists.
Pharmacists.
IPP Fellows.
Timeline (When)
December 2013
Assistance
(How Much)
Technical and financial assistance to do the pilot study
Expected outputs
Achieving Cancer Pain Management. Model at District General
hospital.
Output measurement
Patient satisfaction.
Problem 3: (Cont…)
Inconsistencies on Distribution & Availability of
Opioids at the point of delivery
Objective(s) (What)
To conduct pilot projects on achieving community based
palliative care
Action steps (How)
conducting pilot studies in two districts to provide pain
Authority and/or
Responsibility
(Who)
National Cancer Control Programme.
Provincial Directors of Health services
Directors of each Hospitals..
Oncologists.
Pharmacists.
IPP Fellows.
management.
Timeline (When)
February 2014
Assistance
(How Much)
Technical and financial support.
Expected outputs
Two models in two cultures.
Problem 3: (Cont…)
Inconsistencies on Distribution & Availability of
Opioids at the point of delivery
Objective(s) (What)
Include Oral liquid morphine available.
Action steps (How)
Ensuring purchase of oral liquid Morphine through MSD,
Authority and/or
Responsibility
(Who)
Timeline (When)
National Cancer Control Programme.
MSD.
Assistance
(How Much)
Donation initially from available countries for 2013,
Expected outputs
Availability of Oral Solution of Morphine for Cancer pain Mx.
Output measurement
Report from Director / Hospitals
June 2013
Problem 4:
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting.
• Reasons for the problem..
• In Sri Lanka Health Care Professionals have
varying levels of Knowledge, Attitudes and
Practice towards Pain Management in general
and opioid prescription in particular.
– Imposes barriers to receive opioids for pain
management.
Problem 4: (Cont…)
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting
Objective(s) (What)
To have Continuing Medical Education (CME) on Palliative care and pain
management in each District at least one per year.
Action steps (How)
Discussing this idea with the National Cancer Control Programme to arrange this
programme
Developing guidelines / Desktops / Power point Slides.
Authority and/or
Responsibility (Who)
Secretary, Ministry of Health.
Director Genearal of Health
Director / National Cancer Control Programme
Sri Lanka Medical Association.
Professional Colleges.
Timeline (When)
2013 -2014 ( Year 2)
Assistance
(How Much)
Technical and financial assiaatance .
Expected outputs
Programmes are conducted.
Output measurement
No. of Programmes conducted and reports of them
Problem 4: (Cont…)
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting
Objective(s) (What)
To have detailed component of palliative care module in
postgraduate streams such as Oncology, anaesthesiology and
Family Medicine .
Action steps (How)
To initiate this matter with Director Postgraduate Institute of
Medicine and Boards of study in Clinical Oncology and Family
Medicine.
Authority and/or
Responsibility
(Who)
Timeline (When)
Director PGIM.
Assistance
(How Much)
International Experts (PPSG) and Local experts
Expected outputs
Inclusion of Palliative care components in the curricula.
Output measurement
Prospectus of Board of Study
Chairman BOS in Oncology and Family Medicine
2013 - 2014
Problem 4: (Cont…)
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting
Objective(s) (What)
To commence Postgraduate Diploma course on palliative care
for Medical Officers
Action steps (How)
To discuss this matters with Director, PGIM involving members
from specialties concerned.
Authority and/or
Responsibility
(Who)
Secretary of Health,
Director Genearal of Health Services
Director PGIM.
National Cancer Control Programme.
Timeline (When)
2013-2014
Assistance
(How Much)
Technical support of International Experts (PPSG) to Post
Graduate Institute to develop curricula.
Expected outputs
Acceptance establishment of Curriculum Development
Committee.
Output measurement
Study Prospectus.
Problem 4: (Cont…)
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting
Objective(s) (What)
To include training modules on palliative care nursing to the
basic nursing training curricula
Action steps (How)
Conducting a Training programme for tutors of Nursing
Training Schools
Authority and/or
Responsibility
(Who)
Timeline (When)
Director Genearal of Health
Director / Nursing (Training)
Assistance
(How Much)
Technical support of international experts
Expected outputs
Availability of trained palliative care nursing tutors
Output measurement
No. of programmes conducted.
2014
Problem 4: (Cont…)
Gaps in knowledge, attitudes and practices of health care
professionals on pain management in palliative setting
Objective(s) (What)
To strengthen the knowledge of Nurses in Palliative Care
Services.
Action steps (How)
Conduct Certificate course in Palliative Care for Nurses
Authority and/or
Responsibility
(Who)
Secretary of Health.
Director General Health Services.
Director / Nursing (Training)
Timeline (When)
2014
Assistance
(How Much)
Technical support of international experts
Expected outputs
Availability of trained palliative care nurses.
Output measurement
No. of trained palliative care nurses
Time Line of Activities
To include palliative care as a priority in the Cancer
Policy of Sri Lanka
To establish a National Working Group on Palliative Care
for Cancer Patients
To conduct an advocacy meeting to obtain support from
all stakeholders
To amend the existing law that restrict duration of
opioid prescription
Reviewing the current problem at the Institutional level
including Health System Research in each Cancer
Hospital. (BOAT Survey)
Conducting pilot studies to forecast the amount of
opioids in two cancer centres
conducting pilot studies in two districts to provide pain
management.
September 2012
September 2012
October 2012
2012 - 2014
February 2013
September 2013
December 2013
June 2013
Ensuring purchase of oral liquid Morphine through MSD.
Time Line of Activities (cont..)
To have Continuing Medical Education (CME) on
Palliative care and pain management in each
District.
Inclusion of Palliative care components in the
curricula of Oncology & Family Medicine.
Acceptance establishment of Curriculum
Development Committee.
Conducting a Training programme for tutors of
Nursing Training Schools
Conduct Certificate course in Palliative Care for
Nurses
2013 - 2014
2013 - 2014
2013 - 2014
2013 - 2014
2014
Goal :
Opioid analgesics are
available to the patients who
need them.
Quality of life of patients and
families are improved.
Thank
You