Regional Reports –
Mongolia, Serbia, Australia, USA
Development of palliative care in Mongolia
Situation in Mongolia before 2000.
There were no organizations or hospices engaged in palliative care prior to 2000. Our medical schools did not have a palliative care teaching programs. The government and the Ministry of Health of Mongolia did not have a policy on palliative care. The consumption of morphine in Mongolia was only 1kg/year.
Size of problem:
Mongolia is a large country, extending 1,564,116 km 2, with a small population of 2,9 million. 36% percent of the population lives below the poverty line. The cancer incidence is estimated to be 134.0 per 100,000 populations, around 3,740 per year. 87% percent of the patients present with advanced disease (stage III or IV), and 70% of these cancer patients die within the first year after their diagnosis. The prevalence of adult HIV/ AIDS is presently less than 0.1%.
Historical development of palliative care services in Mongolia.
The Mongolian Palliative Care Society (MPCS) was established in 2000. MPCS is the leading organization in Mongolia that integrates all activities (advocacy, advertisement, education, policy development, drug availability, service) on palliative care. We now have 10 palliative care hospices in Mongolia and all of them are members of MPCS.
A Palliative Care Department (15 bed) in the National Cancer Center (NCC) is the single palliative care organization supported by the health budget in Mongolia. The ten hospices combined have a total of 65 beds, and those without inpatient beds provide home care, outpatient consultation or nursing, spiritual and social care. Additionally, an order of the Ministry of Health (N 307) in 2005 established an agreement to utilize up to 5 beds in province hospitals for palliative care patients. This means, that now patients in need of palliative care from the provinces can now receive inpatient palliative care services within their province.
Education on palliative care.
MPCS translated and published the WHO’s guides on palliative care. Basic and advanced training books on palliative care have been published in the Mongolian language. After receiving support from the Soros Foundation we organized the first basic training courses for 330 doctors, nurses and medical teachers. Since 2002 we have organized 30 courses for more than 1000 medical workers on palliative care. In 2004, MPCS established a Palliative Care Resource Training Center with support of the Soros Foundation. This Center received an official certificate from the Ministry of Health and Ministry of Education of Mongolia to provide specialty education leading to a diploma in palliative care for doctors and nurses. Diplomas have been earned by 120 doctors and 25 nurses who now work in palliative care settings.
Presently, all medical schools provide undergraduate and postgraduate education on palliative care.
Drug availability for palliative care.
We can not improve the quality of life terminally ill patients without essential drugs and appropriate prescription rights. Between 2003 and 2005, MPCS organized drug policy conferences with the support of the Soros Foundation and the Ministry of Health to make morphine affordable and available in Mongolia as well as to change the prescription policy. As a result of these activities, in 2003 a working group in the Ministry of Health approved a new order to improve the prescription rights of doctors. It allows family doctors and palliative care doctors to prescribe up to a seven-day supply of morphine necessary to control a patient’s pain. The first affordable oral morphine from the west coast arrived in February 2006. In early 2006, two teachers from the USA, Dr Frank Ferris and Mary Wilier organized bedside training on the effective use of morphine. Since then, consumption of morphine has increased from 1 kg/year up to 6 kg/year.
Policy Development for palliative care.
MPCS started advocating for the development of palliative care in 2002. We organized leadership conferences on palliative care in Ulaanbaatar. Supported by the Soros Foundation, we had three policy development conferences (2004-2006) for the major policy makers in Mongolia. As a result of these conferences, the Minister of Health approved the order to establish 8 working groups to develop a palliative care policy. As a project leader, I worked as a consultant to these groups and all were successful to finish and report their activities in 2006.
Mongolia now has palliative care services throughout the country and we have standards of practice. There are palliative care education programs at all levels. The palliative care department of the NCC received a health budget and patients from the provinces can receive free inpatient palliative care in all provinces. There are 10 hospices in Mongolia that have specialized palliative care multidisciplinary teams. Palliative care is also included in the health law, the social welfare law, the national cancer program and the national program on non communicable diseases. Mongolia is now one of 35 countries in the world with an integrated policy on palliative care.
I am very proud that we have achieved our goals.
Odontuya Davaasuren MD, PhD, Associate Professor
Mongolian Palliative Care Society
This is to inform you that the National PC Strategy was “officially approved and adopted by the Government of Serbia, on March 5, 2009”. This Strategy recognizes: 1) opioids as essential for pain relief/palliative care, 2) the need for opioid control policy that balances concerns about abuse and the need for medical use, and 3) the need to examine drug control policies for potential barriers and update them in accordance with international conventions and EU requirements.
The objective for changing the national opioid control policy (from Serbia IPPF Action Plan) has now been officially accepted by the Government.
Thank you all for your support, friendship and valuable guidance.
International Fellowship Program of the Pain and Policy Studies Group, University of Wisconsin, Madison
Australasian Palliative Link International (APLI) Newsletter
“APLI is a group of Australian palliative care personnel and supporters interested in the supportive development of palliative care in the Asia-Pacific region.” The APLI newsletter is now published on our website: http://www.petermac.org/apli/default.htm
Dr Odette Spruyt,
Head, Palliative Care Unit
Peter MacCallum Cancer Institute
St. Andrews Place, East Melbourne
“Health Care Costs in the Last Week of Life
Associations With End-of-Life Conversations”
Baohui Zhang, et al. Arch Intern Med. 2009;169(5):480-488.
The conclusion from this study is: “Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.”