Action Plan India Priya, Nandini, Shalini, Dr. Sudhir, Rajesh, Raj, Frank, David

Patients across India receive quality pain management, including opioid analgesics

Problems identified 1.Regulations of central and state governments do not support adequate access to controlled pain medications. 2.Lack of appropriate environment (attitudes, knowledge, skills, and behaviors) amongst health care professionals, policy makers and regulators 3.Lack of access to competent health delivery centers for adequate, effective pain relief 4.Inadequate awareness of public about pain management and use of opioids

Problemsobjective Regulations of central and state governments do not support adequate access to controlled pain medications Ensure alignment with U.N. Single Convention Facilitate RMIs* throughout the country Develop system for reporting of estimates and consumption statistics 1.1 Complex and non-uniform regulations Amend the NDPS Act Frame new central rules for entire country 1.2 No single central government agency with a mandate to ensure access to controlled pain medications Form a consultative committee as per section 6 of the NDPS Act 1.3 Lack of awareness about “the principle of balance” amongst policy makers Support implementation through communication and educational activities 1. Issues on Regulations

1. Action Plan for Issues on Regulations ActionWhoWhen 1.1. Amend the NDPS Act & Frame new central rules for entire country - Language, supportive documents, SOPs - Advocacy at state level Concerned ministries with DOR as nodus IPPF Fellow 6 months after governmental approval to go through both houses Continued engagement with the concerned govt. agencies – until ACT/Rules Passed 1.2 Form a consultative committee as per section 6 of the NDPS Act -Facilitate through interactions with NAC, ministries -Identify members -Frame rules for committe NAC, PMO, MOF and MO Health, PC advocates- to help form DO Revenue to frame rules and notify the committee IPPF Fellow – assist with resource Continued engagement with the concerned govt. agencies

Action Steps 3.1. Develop an online system for registration and return filing of manufacturers/wholesalers to enable gathering of consumption statistics as defined in the Single Convention 3.2. Give input on the importance of consumption statistics for monitoring and research for 160 manufacturers/wholesalers. - Identify the ideal format for the statistics (e.g. by RMI, state, etc.) 3.2.a Be alert for blockages in the system that lead to stock-outs and impact patient care 3.3. Get manufacturers/wholesalers to register Who has A/R 3.1. Narcotics commissioner, CBN 3.2. Fellows and other experts 3.3. Narcotics commissioner, CBN When year months months after system is created Assistance3.1. MoF will sanction funds 3.2. IPPF fellows - Consultation from PPSG 3.3. N Commissioner - host workshops with manufacturers + PC experts OutputsOnline system is in place, Accurate consumption statistics are available 1.Ensuring accurate reporting of estimates and consumption statistics

1.3 Lack of awareness about “the principle of balance” amongst policy makers WhatWhoWhen Communication and educational activities to sensitize policy makers / regulators Centre - Health ministry Dept. of Health and Family Welfare State - Health secretory or his nominee PC advocates – National PC bodies IPPF Fellow - Making a plan – 3 months - Approval of / consensus – 6 months - Implementation of plan – 1 year 1.Development of strategy 2.Develop consensus plan amongst key stake holders 3.Mobilize resources 4. Implement the plan

Problems identified 1.Regulations of central and state governments do not support adequate access to controlled pain medications. 2.Lack of appropriate environment: (attitudes, knowledge, skills, and behaviors) amongst health care professionals, policy makers and regulators 3.Lack of access to competent health delivery centers for adequate, effective pain relief 4.Inadequate awareness of public about pain management and use of opioids

2. Lack of appropriate environment Health care professionalsHow? Capacity building -doctors, administrators,, nurses, pharmacists -government and private sector Creation of manual 1. guidelines for pain assessment and management 2. SOPs for access to strong analgesics 3. Information regarding safe usage Implement undergraduate teaching on pain management 1.Faculty empowerment workshops [25 medical colleges] 2. Conduct training program through identified training centres – X number / year/ centre 3. Develop and implement discipline specific plans and monitor outputs and outcomes Who? IPPF fellow, Stakeholders H Secretory, DGHS MCI, NCI, Pharmacy council National organisations in Palliative Care, ISSP When? Formation of key group – 3-6 months Making a plan, consensus – 9 – 12 months Implementation of plan 3-5 years Healthcare professional training - continued

Problems identified 1.Regulations of central and state governments do not support adequate access to controlled pain medications. 2.Lack of appropriate environment: (attitudes, knowledge, skills, and behaviors) amongst health care professionals, policy makers and regulators 3.Lack of access to competent health delivery centers for adequate, effective pain relief 4.Inadequate awareness of public about pain management and use of opioids

3. Lack of access - what? Creating capacity and implementation of effective pain management/services in Government run HC providers - NPCDCS (primary, secondary and tertiary) Private health care institutions Facilitating new pain/palliative care centers through NGOs Contents – addressing the 3 aspects of availability and accessibility a)Education of professionals & public awareness b)Opioid access and c)Implementation of pain policy by WHO method

3.Lack of access – How? Government 1.Creation of Technical Resource Group (TRG) in Ministry of Health & FW for palliative care 2.Identification of training centers in Delhi and in 10 other places in India – government 3.Design training program in pain management in palliative care for doctors and nurses 4.Start dedicated pain /palliative care services through 5 RCCs & 20 other hospitals including medical college hospitals Who? 1.A national level Policy Centre - Director General of Health services State - health Secretary 2.Technical Resource Service Group (TRG) 3.Palliative care organizations (Pallium India, IAPC) 4.Identified palliative care organizations

3.Lack of access – How? Government 1.Creation of Technical Resource Group (TRG) in Ministry of Health & FW for palliative care 2.Identification of training centers in Delhi and in 10 other places in India – government 3.Design training program in pain management in palliative care for doctors and nurses 4.Start dedicated pain /palliative care services through 5 RCCs & 20 other hospitals including medical college hospitals When? 1.2 months 2.4 months 3.4 months 4.8 months to 2 years and ongoing

3.Improving access in Private sector 1.Explore ways of influencing accreditation process for implementation of institutional pain policy as essential requirement for hospitals 2.Approach major health insurance schemes to include palliative care in their coverage 3.Advocacy through IMA & other major professional bodies 4.Sensitize Chains of hospitals 5.Promote Scholarships through government / foundations 6.Establish systems for appreciation( Centres for excellence ) Who – IPPF Fellows along with the MOH support and PC fraternity When – sincere efforts ongoing - ??

Problems identified 1.Regulations of central and state governments do not support adequate access to controlled pain medications. 2.Lack of appropriate environment: (attitudes, knowledge, skills, and behaviors) amongst health care professionals, policy makers and regulators 3.Lack of access to competent health delivery centers for adequate, effective pain relief 4.Inadequate awareness of public about pain management and use of opioids

4. Inadequate awareness of public What?Who?When? Campaign to increase awareness and shifting attitudes of public about effective pain management including opioids Indian Association of Palliative care. Indian Association of study of pain. Pallium India Disease interest group such as Indian Cancer society Selected Media personalities Selected healthcare NGO’s

Assistance Finances for education and awareness – NPCDCS funds, MoH – WHO India – Private foundations Policy – Department of Narcotics control - amendments – Lawyer’s Collective Policy implementation and educational activities – Pallium India, IAPC

Expected outputs Amended NDPS Act New Model rules applicable uniformly throughout India At least 2 RMIs per district All healthcare professionals learning and executing effective pain management