Palliative care in Tajikistan: an emerging health service

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Palliative care is an emerging health care service in Tajikistan. At present there are four programs delivering palliative care, three are pilot projects supported by the Open Society Institute Assistance Foundation – Tajikistan (OSIAFT) and the fourth is at the Infectious Disease Hospital in Dushanbe. Services began in 2011. Together the programmes serve about 400 patients per year and also provide palliative care support to approximately 800 family members. 

The need for palliative care

The need for palliative care in Tajikistan has been estimated at 15 000 patients and their families per year. This translates to approximately 2465 patients per day, 90% of which would need to receive care in their home setting and 10% in inpatient facilities. A projection of 275 inpatient beds for palliative care has been made. Approximately 20% of the need for palliative care in Tajikistan is for cancer patients and 80% for other conditions such as cardiovascular disease, chronic obstructive pulmonary disease, drug resistant TB, HIV, diabetes, cirrhosis, kidney disease and other complex chronic conditions. Children may also need palliative care services both in the neonatal period and from congenital and other chronic conditions. 

Access to essential palliative care medications is limited. In particular registration and coverage for oral morphine is needed to ensure adequate pain control for cancer patients and others with moderate to severe chronic pain. All palliative care medications listed in the WHO Model List of Essential Medicines should be available for palliative care patients. 

Reform of the existing health care structure is needed to shift underutilized resources to support the growth of palliative care services, especially so that home based care can be delivered. The existing pilot palliative care programs can be used as teaching centres and models for the expansion of palliative care throughout the Republic. A growing number of palliative care advocates have emerged and the community is beginning to recognize that palliative care is a needed and necessary part of the health care system in Tajikistan. Pain and suffering are not an unavoidable consequence of life threatening illness and palliative care is now seen as a human right.

Government policy

There is increasing government support for palliative care development in the country and Tajikistan is taking a lead in the Central Asian Region in palliative care development.

Palliative care is included in the National Health Strategy for the population of Tajikistan for the 2010-2020 period. A national strategy for the implementation of palliative care is under review by the government and efforts are underway to include palliative care as a recognized part of the health care system in Tajikistan. Palliative care is included into the National Cancer control Program and the Programme on the response to the epidemic of HIV/AIDS in the republic of Tajikistan for the period 2011-2015. 

Palliative care education is now included as a compulsory subject in the curriculum of the State Medical University and all eleven nursing schools and four medical colleges have added palliative care as a compulsory subject and all nursing students are receiving basic education in palliative care. The Postgraduate Institute for Medical Specialists also included a palliative care education refresher courses for all medical subspecialties.

Three comprehensive palliative care models were designed, including an in-patient unit, a day care centre and home care programme, as well as the creation of professional interdisciplinary teams.

Oral morphine is included in the List of essential drugs in Tajikistan in the following forms: solution for oral administration (hydrochloride or sulfate) 10mg/5ml ; Immediate release 10 mg-Tablet (sulfate); slow release tablets 10mg, 30 mg, 60mg.

National standards for the provision of palliative care in Tajikistan have been developed and submitted for the approval for the level of Ministry of Health and Social Protection .

In our country with limited resources, in order to develop sustainability for our pilot models, the first point is collaboration with government. The main aim is to make sure that palliative care is an integral part of health care system in Tajikistan, together with a developed model of home based care. All of our initiatives on education for specialists are now run by the government. All main strategic documents for the Ministry of Health and Social protection have included palliative care as a priority for development.

Palliative care education

The total population is not very aware of palliative care. Only those who have participated in our training and information sessions or training films seen on television have a knowledge of palliative care. This underlines the importance of educational campaigns and therefore we have supported one grant implemented by Republican Nurses Centre on education for religious leaders and population in rural areas – annually their trainers are educating 132 religious leaders and raising awareness about the palliative care principles and approaches among about 5000 people in two provinces of Tajikistan.

Future of palliative care in Tajikistan

We are so happy about the resolution on palliative care that was passed recently by the World Health Assembly. We are going to use it as an advocacy tool to promote the development of palliative care issues on a different level. For example,  I participated on June 19-20 in the Regional Forum with participation of country teams from Kazakhstan, Kyrgyzstan and Tajikistan on TB Prevention and Treatment among Migrants within the USAID Dialogue on HIV and TB Project that was held in Dushanbe. Palliative Care development for the TB program was included in the final document of the Forum. Also we are planning to include palliative care in the next funding model of Global Fund for Tajikistan for 2015-2017. This document will help to promote this approach.

In the future, I see palliative care developing in Tajikistan in the following ways:

  • Further development of paediatric palliative care
  • Clinical guidelines and protocols for palliative care need to be adapted for use in Tajikistan
  • A funding mechanism needs to be established to encourage the expansion of palliative care. Reductions in cost for hospitalization could be used to grow interdisciplinary palliative home care and palliative care should be included in the basic benefits package. An economic impact analysis is needed.
  • Support the development of a National Association for palliative care providers
  • Gradual scale up of home care teams and inpatient units should be undertaken to meet the need identified in the strategic plan for palliative care
  • Inclusion of palliative care in the next funding model application for Global Fund funding for Tajikistan 2015-17. This funding will be needed to meet the palliative care needs for the approximately 1500 patients per year with HIV or TB.
  • Palliative care education needs to be included for law enforcement bodies, including drug control agencies and Ministry of Internal Affairs in order to insure the balance between drug control and availability of opioid analgesics for patients with palliative care needs.

Read about specific palliative care programmes in Tajikistan on ehospice this week.

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