What led to the permanent mission of Panama driving the sponsorship of the resolution, ‘Strengthening of palliative care as a component of integrated treatment within the continuum of care’?
Panama participated in a side event at the World Health Assembly in 2012, sharing the experience of the National Palliative Care Program, which formally began in 2010. This information had a huge effect on the members of the Permanent Mission of Panama to Geneva. The country, as a member of the Executive Board of WHO, decided to take action to ensure that no person with an incurable disease has to suffer without treatment from pain or other symptoms, and that respect for human rights and dignity was emphasized.
In 2013, our country participated in a second side event, during which Dr Serafin Sanchez, Deputy Minister of Health for the Republic of Panama, was one of the speakers. The Panamanian Ambassador to Geneva, Ambassador Alberto Navarro Brin, and Jorge Corrales, counsellor of the permanent mission of Panama to Geneva, were active participants, as was Dr Zelibeht Valverde who developed the draft resolution on palliative care in conjunction with countries and NGOs.
The draft resolution articulated the need for palliative care across different disease groups and levels of care within the national and international perspective, beyond cancer and HIV with a focus of attention on patient centred care, home-based care and integration into primary health care. This is consistent with the palliative care philosophy and vision of the National Palliative Care Program of Panama. The technical and diplomatic team who worked on the draft resolution conducted a real intersectoral partnership that enabled a highly effective partnership between technicians, WHO, and NGOs.
Can you describe the current state of palliative care in Panama?
Panama has a National Palliative Care Committee made up of volunteers from the University of Panama, Social Security, Ministry of Health and NGOs such as HOSPES and Fundacáncer. There is a national standard Palliative Care Program, which provides technical guidance on issues such as information systems, processes for the obtaining of medicines and supplies, advice against burn out, etc.
The National Palliative Care Committee has support from the executive level of government in the form of the Presidency of the Republic and the office of the First Lady, as well as the Ministry of Health. The University of Panama, Universidad Latina and the Technological University of Panama are involved in palliative care research and education, and NGOs such as HOSPES, Fundacáncer and ANCEC have for many years provided excellent care and training at the community level. The Office of National Health Service Provision contributed medication purchases support to the program with funding from the anti-Tobacco Act.
There is a national coordinator of the Ministry of Health and Social Security, and in the 14 health regions of the country there are palliative care program coordinators, as well as health staff trained in the basic program criteria for hospice and home care patients and patients with advanced disease. These staff have access to advice from specialists national hospitals, including the National Cancer Institute. There is a web page for the recording and reporting of the coordinators of palliative care, and construction of a social network web for the National Palliative Care Program is underway in collaboration with the Technological University of Panama.
Morphine use in Panama (including raw materials) increased from 0.67 mg /capita in 2006 to 1.15 mg /capita in 2012, according to calculations by Martha A. Maurer (MSSW, MPH, PhD, Researcher and Program Manager Policy Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center, WHO Collaborating Center for Pain and Palliative Care Policy).
In 2010, about one thousand patients were treated in the National Palliative Care Program. At that time nearly all were treated in the palliative care unit at the National Cancer Institute (ION). This number increased to 1975 in 2011, and 2967 in 2012. While in 2011, 30% were in different facilities to the National Cancer Institute, in 2012 this figure increased to 54%. This implies a high degree of decentralization of the program and improved access to the National Palliative Care Program.
Are opioids available in the country? Who can prescribe?
In Panama we have morphine oxidocona, codeine, tramadol and fentanyl. Infusers are used when needed and our regional health teams are able to apply the different means of administration of opioids.
The collaboration between regulatory authorities and the use of opioid prescribers is good. The group of prescribers and/or clinicians interested in improving access to legitimate use of opioids is now part of the National Palliative Care Commission. This group’s collaboration with regulatory authorities has intensified since 2006 with the support of the current Vice-Deacon of the Faculty of Pharmacy of the University of Panama, Rosa Buitrago, who is also a fellow of the Pain & Policy Studies Group (PPSG) at the University of Wisconsin and the International Association for Hospice and Palliative Care (IAHPC). Dr Buitrago is also a member of the Faculty of Pharmacy of the University of Panama and the National Cancer Institute Juan Demóstenes Arosemena (ION).
Opioid legislation dating from 1954 is being revisited and does not correspond to current needs. However, all physicians can prescribe opioids. With Executive Decree 320 of June 17, 2009, the number of days for which opioids could be prescribed increased to 15 days in the case of medicines for parenteral routes and 30 days if they are administered orally. This decree marked a significant change in the prescribing, dispensing and distribution of opioids.
With the National Palliative Care Program, the Ministry of Health included opioids in its list of drug purchases. Opioids are delivered to local and regional health centres and health care staff are trained in their use.
What change do you hope will come about as a result of the resolution?
The adoption of the resolution on palliative care by WHO is an acknowledgement of all the important work being done in this field. In Panama, it promotes the sustainability and growth of the National Palliative Care Program. Being a recommendation of WHO, the Social Security of Panama will find it easier to include palliative care in their budget, and hopefully this will have a similar effect in other countries.
At a global public health level, I consider it to be a great achievement that will provide to end of life care a similar interest as that which is given to prenatal care. Everyone deserves health care from conception to death, and it is unforgivable not provide comprehensive care in many countries at the end of life.
The inclusion of spiritual care in the full resolution is vital, given the existential crisis involving the end of life for both the patient and their family.
Palliative care should be an integrated part of Universal Health Coverage. This resolution is a big step in that direction.
Watch ehospice for updates on the progress of the WHO resolution at the World Health Assembly in May this year.