June 2, 2011

VII. Asia

Regional Overview

"My leg would burn like a chili on your tongue. The pain was so severe I felt like dying. I was very scared. I felt that it would be better to die than to have to bear this pain. [I thought], just remove the leg, then it will be alright. Just get rid of the leg so I'll be free of pain."
- Dilawar Joshi, a Nepali man with a bone tumor, India
"I would sleep maybe an hour and a half per night. I could take any number of sleeping pills [without effect]. With morphine, I can relax. This place [the palliative care unit] is heaven-sent..."
- Shruti Sharma, Hyderabad, a breast cancer patient, India

Consumption of opioids varies dramatically throughout Asia. Australia and New Zealand consume more than 20 times more opioids than are needed to treat their terminal cancer and HIV/AIDS patients. By contrast, Bhutan, North Korea, India, Indonesia, the Maldives, Mongolia, Nepal, and Sri Lanka can all treat less than 20 percent of their terminal cancer and HIV/AIDS patients, and Bangladesh, Burma, Cambodia, Laos, and Vietnam less than 10 percent. The Solomon Islands reported no consumption of opioids at all between 2006 and 2008.

The world’s two most populous countries—India and China—can treat just 12 and 53 percent of their terminal cancer and HIV/AIDS patients respectively. Thus although Asia has better treatment coverage than sub-Saharan Africa, it also has the largest number of patients suffering without treatment of any region, at least 1.7 million terminal cancer and HIV/AIDS patients.

Policy

While nine of eleven countries surveyed reference palliative care in their national cancer control policies (Cambodia and Nepal are the exceptions) only four of eleven—Indonesia, Philippines, South Korea, and Vietnam—have national palliative care policies. Only three countries— Cambodia, Nepal, and Vietnam—provide for palliative care in national HIV policies. Oral morphine is a registered medicine in all the countries surveyed, and both oral and injectable formulations are on the essential medicines lists of all countries except South Korea. Vietnam stands out as the country that provides the best policy support for palliative care, with a national palliative care policy and palliative care provisions in its national cancer and HIV plans.

Table 23: Pain Treatment and Palliative Care Policies in Asia

Education

Availability of instruction on palliative care in undergraduate medical programs is poor in most countries in the region surveyed, with Bangladesh and Nepal, which both offer compulsory instruction on palliative care in most undergraduate medical programs, performing best. Palliative care instruction is available only in few undergraduate programs in India, Indonesia, and South Korea. In Cambodia, Philippines, South Korea, and Vietnam, no compulsory instruction in palliative care is available in any undergraduate medical programs. Key informants in most countries said that instruction on palliative care was available in post-graduate medical education, but in China such instruction is not available at all.

Table 24: Availability of Education in Pain Management in Asia

Drug Availability

Key informants in Cambodia, China, Japan, and South Korea reported the widest availability of morphine, with the medication available in most or all hospitals. However, in Cambodia and China, oral morphine is not available at all in pharmacies and in few or no health centers, creating significant obstacles to its accessibility in rural areas. Poorest overall availability was reported in Bangladesh, where oral morphine is not at all available in hospitals and health centers and only in some pharmacies and few hospices in India, Nepal, Philippines, and Vietnam. In each of these countries oral and injectable morphine is available only in some hospitals, health centers, and pharmacies, although reported availability in hospices is slightly better. Doctors in all the countries surveyed in Asia reported that morphine is harder to access outside major cities.

Table 25. Accessibility of Morphine in Different Healthcare Settings in Asia

Medicines Availability: Restrictive Regulation

Of the 11 Asian countries surveyed, Cambodia has by far the most restrictive regulations. It prohibits prescribing of morphine for home use, requires doctors to get a special license to be allowed to prescribe morphine, requires multiple doctors to sign off on morphine prescriptions, and imposes a 7-day limit on the number of days a prescription can cover.

Seven of the ten other Asian countries surveyed require a special prescription form for morphine—India, Indonesia, and Nepal are the exceptions—and three others, China, Japan, and Philippines, require doctors to obtain a special license before they can write such prescriptions. Regulations in four of the other ten countries imposed limitations on the number of days a prescription can cover. In Japan, Philippines, and Vietnam, the limit is a relatively generous 30 days. In China, it depends on the formulation of morphine: 15 days for sustained release, 7 days for immediate release, and 3 days for injectable morphine. Survey respondents in South Korea, where regulations do not impose such limit, said that many hospitals enforce their own limits, which are often as short as one week or even one day. In all but two of the countries surveyed in the region—Japan and Thailand—doctors reported that fear of legal sanction deters opioid prescribing.

None of the countries surveyed in Asia allow nurse-prescribing, although Vietnam allows assistant doctors to prescribe morphine in remote areas (see below).

Table 26. Restrictive Regulation of Morphine Prescribing in Asia

Cost

The cost of morphine varies markedly throughout the region. The price can be very inexpensive in countries that have domestic production of morphine, including India and Vietnam, and other countries, including Japan and China, subsidize its cost. In some countries, including Nepal, there is an official government price for morphine, but shortages mean the price on the black market is sometimes much higher.

Developing Palliative Care: Vietnam

Between 2005, when palliative care reforms began, and 2008, Vietnam saw an over 800 percent increase in morphine equivalent consumption, from 0.3 mg per person to 2.5 mg per person. [113] Vietnam has focused its reform efforts on removing unnecessary barriers to prescribing opioids and educating healthcare personnel in palliative care. In 2008 the country eased a number of key regulatory barriers to opioid prescription: the maximum daily opioid dose was abolished, prescriptions can now be issued for 30 days rather than 7, and district hospitals and commune health posts are now authorized to prescribe and dispense morphine. [114] Assistant doctors in “mountainous, remote, island, disadvantage areas and places where a doctor is not available” are also now able to obtain a license to prescribe morphine. [115]

New education programs and opportunities have also been developed. In 2008 the Ministry of Health piloted a certification program in palliative care and held a two-day workshop on new palliative care guidelines and regulations for more than 1,000 health care managers, pharmacists, and physicians from around the country. [116] As of 2010, 400 Vietnamese doctors have completed a one-week curriculum in palliative care, developed with assistance from the Harvard Medical School Center for Palliative Care. [117] Two Vietnamese medical colleges now offer instruction on palliative care to undergraduate medical and nursing students, and a National Curriculum in Palliative Care was expected to be published in 2010. [118]

This progress started with the creation of a working group on palliative care, which consisted of Ministry of Health officials, cancer and infectious disease physicians, and experts from NGOs supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The working group decided to conduct a rapid situation analysis to assess the availability of and the need for palliative care in Vietnam. [119] Based on the rapid situation analysis’s findings, the working group recommended that national palliative care guidelines and a balanced national opioid control policy be developed, training for healthcare workers be expanded, and that availability and quality of palliative care services be improved at all levels. In September 2006, the Ministry of Health issued detailed Guidelines on Palliative Care for Cancer and AIDS Patients, which provided guidance to practitioners on palliative care and pain management, and in February 2008, it issued new guidelines on opioid prescription, which eased regulatory barriers as described above.

Despite this progress, numerous challenges remain in delivering palliative care in Vietnam. Attitudes toward, and an understanding of, palliative care among health care professionals continue to be limited and lag behind regulatory changes. Although morphine can be prescribed for 30 days, a prescription can only be filled for 10 days a time, after which point it must be confirmed that the patient is alive and using the medication appropriately. [120] The availability of opioids continues to be limited, especially in rural areas, as few pharmacies and hospitals stock oral morphine.

[113] Consumption Data. International Narcotics Control Board.

[114] While this is an improvement, patients and their families can only fill prescriptions for 10 days at a time, after which their local commune must confirm in writing that the patient is still alive.

[115] Human Rights Watch interview with Dr Eric Krakauer, November 3, 2009.

[116]Eric L. Krakauer, Nguyen Thi Phuong Cham, Luong Ngoc Khue. Vietnam's Palliative Care Initiative: Successes and Challenges in the First Five Years. Journal of Pain and Symptom Management, 2010 40(1): 27-30.

[117]Ibid.

[118] Human Rights Watch interview with Dr Eric Krakauer, November 3, 2009.

[119]Green K, Kinh LN, Khue LN., “Palliative care in Vietnam: Findings from a rapid situation analysis in five provinces,” (Hanoi: Vietnam Ministry of Health, 2006).

[120] Human Rights Watch interview with Dr. Eric Krakauer, November 3, 2009.