Major progress in palliative care and access to medicines in Armenia

While these changes appear to have happened suddenly, they are in fact the result of a very long and steady advocacy effort.

In 2010 the Open Society Institute Assistance Foundation Armenia (OSIAFA) began an effort to help local champions develop palliative care in the country.

As part of their public health programme a palliative care project co-funded by the OSF New York International Palliative Care Initiative (IPCI) was started.

Dr Stephen R. Connor was assigned from IPCI as an international palliative care consultant to assist the local coordinator of the public health programmes, Ms Anahit Papikyan, to carry out the project.

Over the course of the next few years frequent trips were made to the country with some of the following outcomes:

• a national needs assessment was conducted estimating that over 18,000 people per year needed palliative care
• a Ministry of Health (MoH) sponsored working group on palliative care was formed
• national standards were developed for palliative care service operation and eventually approved by the MoH
• national clinical guidelines on pain and symptom management were also approved by MoH
• an analysis of laws and regulations was conducted and a set of changes to the laws and rules governing access to controlled substances were drafted
• Global Fund and OSIAFA supported four pilot palliative care projects that ran for two years and were evaluated
• a national concept paper on palliative care development was accepted by the government and led to inclusion of palliative care in the national health care strategy.
• palliative care was included in the national  control program, the national HIV and TB strategies.
• palliative care educational curricula were developed and implemented in the medical university, nursing colleges, and university psychology department.
• several attempts to register oral morphine were undertaken without success.

Progress in palliative care is often dependent on who is occupying the post of Minister of Health and whether there is support from deputy ministers and other Ministers including Economics, Internal Affairs, and Justice.

After much progress and much frustration Human Rights Watch published a report in 2015, titled: ‘All I can do is cry’ on the lack of access to palliative care and pain relief in Armenia. This report did not cause significant response from the Ministry of Health at the time.

However, the post of Minister of Health changed in 2016 and the new Minister is very interested in seeing some progress on palliative care and removing many current restrictions that limit opioid prescribing to only oncologists under very strict rules. This resulted in the following actions that have taken place in the last few months:

• psychotropic medicines can now be prescribed by family doctors, as well as by treating doctors (irrespective of their specialty)
• there is no standing commission to make a decision on whether such medications may be prescribed for individual patients
• the prescription is signed by a treating physician, and signed and sealed by the head of the medical institution (in case of absence of the head of the institution, the prescription can be signed and sealed by the deputy head)
• the medications are prescribed for 10 days and the prescription is valid for 10 days instead of the current three days
• the medications can be prescribed in the health institution and at home during a home visit by the treating doctor.
• the medications can be also received by a legal representative of a patient
• the prescribed medications (as well as the dosage, date and time) are registered in a special journal
• the following data shall be recorded in the journal sealed by the head of the medical institution: serial number, entry order number, the date received, quantity, to whom the prescription was given, the name, surname of the treating physician, the signature of the physician 
• in the patient’s medical record the physician records the name, dosage, type of medication, routes of administration of the medication and frequency of administration.

Even more importantly, the Ministry of Health approved the first purchase of oral morphine for the country to arrive by the end of this year.

With the above changes and the availability of oral morphine all the good planning and training may finally begin to take hold and palliative care start to become a reality.

There are still many barriers to overcome but perseverance has won out.

Read more on the Human Rights Watch website.