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 Opioid Availability Action Planning Worksheet Madison, Wisconsin, USA 6 – 10 August 2012

2. 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 10 August 2012

3. University of Wisconsin Pain & Policy Studies Group World Health Organization Collaborating Center for Pain Policy and Palliative Care Provinces (9) & Districts(25) of Sri Lanka

4. Sri Lanka Nine Provinces. Nine Cancer Units

5. Types of Hospitals Teaching Hospitals Provincial General Hospitals District General hospitals Base Hospitals Divisional Hospitals. Central Dispensaries.

6. National Cancer Control Programme, Sri Lanka 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 Advisory Committee on Cancer Control

7. Ministry of Health National He al th Council National Cancer Control Programme (NCCP ) National Cancer Institute (Maharagama) 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 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

8. Issue Inadequate Patient access to Opioid Analgesics

10. 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

11. 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.

12. 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 outputsPalliative Care is an essential component in the National Cancer Control policy. Output measurementRelevant palliative care Policy statement.

13. 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 National Cancer Control Programme Timeline (When) September 2012 onwards 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

14. 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 measurementReport of advocacy meeting

17. Guest Lecture : Palliative Care

19. Symposium on Palliative Care – 2010

21. 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”

22. 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

23. 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.

24. 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.

25. 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 outputsTo see the estimates. Output measurementThe reports of estimates.

26. 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.

27. 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) c onducting pilot studies in two districts to provide pain management. Authority and/or Responsibility (Who) National Cancer Control Programme. Provincial Directors of Health services Directors of each Hospitals.. Oncologists. Pharmacists. IPP Fellows. Timeline (When) February 2014 Assistance (How Much) Technical and financial support. Expected outputs Two models in two cultures. Output measurement Project Reports.

28. 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) National Cancer Control Programme. MSD. Timeline (When) June 2013 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

29. 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.

30. 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

31. 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) Director PGIM. Chairman BOS in Oncology and Family Medicine Timeline (When) 2013 - 2014 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

32. 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.

33. 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) Director Genearal of Health Director / Nursing (Training) Timeline (When) 2014 Assistance (How Much) Technical support of international experts Expected outputs Availability of trained palliative care nursing tutors Output measurement No. of programmes conducted.

34. 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

35. To include palliative care as a priority in the Cancer Policy of Sri Lanka September 2012 To establish a National Working Group on Palliative Care for Cancer Patients September 2012 To conduct an advocacy meeting to obtain support from all stakeholders October 2012 To amend the existing law that restrict duration of opioid prescription 2012 - 2014 Reviewing the current problem at the Institutional level including Health System Research in each Cancer Hospital. (BOAT Survey) February 2013 Conducting pilot studies to forecast the amount of opioids in two cancer centres September 2013 conducting pilot studies in two districts to provide pain management. December 2013 Ensuring purchase of oral liquid Morphine through MSD. June 2013 Time Line of Activities

36. To have Continuing Medical Education (CME) on Palliative care and pain management in each District. 2013 - 2014 Inclusion of Palliative care components in the curricula of Oncology & Family Medicine. 2013 - 2014 Acceptance establishment of Curriculum Development Committee. 2013 - 2014 Conducting a Training programme for tutors of Nursing Training Schools 2013 - 2014 Conduct Certificate course in Palliative Care for Nurses 2014 Time Line of Activities (cont..)

37. Goal : Opioid analgesics are available to the patients who need them. Quality of life of patients and families are improved.

40. Thank You