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Argentina
166
Journal of Pain and Symptom Management
Vol. 24 No. 2 August 2002
Argentina: Palliative Care Status 2002 Roberto Wenk, MD and Mariela Bertolino, MD Argentine Program of Palliative Medicine-Fundación FEMEBA, Buenos Aires, Argentina
Introduction Half of Argentina’s 35 million inhabitants live in the urban areas scattered throughout the country’s 23 provinces. The health services comprise 3 providers: public services (50% of the population with 81,000 beds), mutuals or social plans (45%), and a private sector (5%). Health care development varies considerably, with areas of excellent medical facilities and others with insufficient basic primary care.1 At present, the country is undergoing a severe economic and social crisis, which has huge repercussions in the health system. The purpose of this paper is to describe the status of palliative care (PC) in Argentina. Much is known, but some information could be incomplete because there are no up-to-date national data.
patient-family unit does not receive help with its practical, social and emotional needs. If a patient does not “fit” into the available curative treatment, the chances are that he or she will be practically forsaken by the health system. At the San Nicolás Palliative Care Center, 146 advanced cancer patients were managed during the period of July 1999–July 2001. At the initial consultation, it was noted that, even though 66% had health benefits and 42% were in touch with their primary care physician, more than half (55%) had not undergone any symptomatic treatment and were suffering 6.5 2.6 (mean SD; range 1–11) different symptoms. The average pain intensity was 7 2 (range 2–10). This is applicable to what happens in most of our cities.
Palliative Care Development Situation of Patients with Advanced Incurable Diseases PC is not systematically recognized as a medical practice and is not included in health plans. Few public institutions offer it and prepaid or social health plans seldom accept it. As a general rule, this situation exposes patients with advanced incurable diseases to undertreatment or therapeutic methods that are ineffective or not adequate for their needs. This group of patients receives the conventional care now available in health institutions. In most cases, it is incomplete. Patients suffer from multiple uncontrolled symptoms and the
Address reprint requests to: Roberto Wenk, MD, Juncal 860, 1062 Buenos Aires, Argentina. © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
PC began to be offered in 1982. Our cultural and economic characteristics modeled its development in three consecutive stages:2 A. Horizontal. It works and expands “on surface” in the same level of motivation and dedication within the community and nongovernmental organizations (NGOs). In numerous cities, volunteers and professionals of different health disciplines care for the patient-family unit and establish links with the health net, the complexity of their activity depends on available resources. It has sustained development. B. Ascendant. Results obtained in (A) triggered activity in superior levels of organization in the community (i.e., municipalities, hospitals, universities) after captivating their authorities’ interest. People from teams initiated and developed in the community provide assistance and teaching at hospitals and universities. 0885-3924/02/$–see front matter PII S0885-3924(02)00444-X
Vol. 24 No. 2 August 2002
C. Descendent. Results obtained in (A) and (B) produced changes at the official organization level. The most important consequences due to health authorities’ interest in this issue are: 1. On August 22, 2000, the Ministry of Health and Social Activities approved by resolution 643/2000 the National Standards for Organization and Operation in PC, developed by its Medical Care Quality Guarantee Program in collaboration with different institutions.3 These standards require that the treatment unit (patient and family) is admitted to one of the different 3 levels and can shift between them according to suffering or impairment of quality of life. The differences between levels are established by (a) specific assistance goals, (b) team characteristics, (c) each discipline’s functions and its shared or specific activities, (d) its operation, (e) the criteria applied for referral among levels, (f) equipment, and (g) services and support institutions. 2. On October 25, 2000, the Ministry of Health and Social Activities approved the recognition of PC as a medical practice, its inclusion in the minimum obligatory health provisions, and its inclusion in health plans and medical health systems. This is the starting point of an automatic administrative process that will sequentially determine the recognition of PC as a medical practice and its inclusion in health plans and medical health systems.
Palliative Care Practice Almost all PC programs provide partial care, with variations related to their particular development: individual work, limited availability of teams, care in an institution or at home, presence or absence of specific facilities, etc. Economic restrictions and a health policy that places no emphasis on PC impede the availability of the components for a full PC program (24/7 care, in consulting room, at home, day hospital service, hospitalization). The characteristics of these programs are as follows: Patients. Most are cancer patients, but lately the spectrum increased with the inclusion of
Argentina
167
AIDS and other chronic and/or degenerative diseases. There are far more teams treating adults patients than those treating pediatric patients. Teams. Although there are only approximately 70–90 recognized active teams throughout the country, PC activity can be identified in every major and medium-sized city. • Disciplines. The teams can include two or more disciplines. All have a minimum of one MD that join with nurses, psychologists, social workers, pharmacists, volunteers, chaplains, depending on both the availability of professionals in the area and the patient’s clinical situation. Most teams comprise only two disciplines. • Dedication. Most teams include part-time professionals. Very few can dedicate fulltime work to PC because the remuneration does not encourage it; the bulk of their work is done in other fields. • Members’ earnings. Some team members are paid and some are volunteers; most groups have mixed personnel. Few health systems pay fees for PC services and most of the remunerated ones are not paid enough. In the public system, most of the professionals work without additional pay. • Development stage. Some teams are just on the project stages, others are developing, and still others (approximately 10–15), are fully implemented. There is an increase of professionals interested in creating new teams. • Teaching and research tasks. All teams perform internal teaching in their institution and frequently also outside teaching. Several training systems are already implemented: university or non-university courses, single or interdisciplinary, distance education system or with a heavy hourly practice. The diverse types of learning methods allow the professionals or volunteers to acquire or complete their education. The curriculum for oncology at different universities includes specific PC modules. Research is in the initial phases, but several teams recognize the importance and need of producing local data. • Assistance. Outpatient consultations are available in all programs. Day care services
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are provided in few institutions; this area is still in the development stages. Home care is practically non-existent in the public system, but has a wider development in the private sector and social organizations. Only two public institutions have PC-specific areas for in-patients (PC units), with a total of 12 beds for the country. Institutions. Public and university hospitals, private clinics and NGOs.
Barriers to Palliative Care Implementation Distribution of resources. Most of the human and material resources in the health care system are dedicated to curative treatments. PC as a medical practice is not yet included in the health plans: A 1996 survey shows that less than 10% of both prepaid and social health plans will pay for PC and a 1998 poll revealed that only 7 out of 33 public hospitals in Buenos Aires, have active PC teams.4–5 Once again, San Nicolas can be used as an example: A city with a population of 150,000, with 1 public hospital and 3 private clinics, 450 beds, over 400 doctors, 2 cardiac surgery services, 2 hemodynamia teams, 4 CAT scans, 3 oncology teams, 3 ICUs, etc. Despite this oversupply of health resources, most advanced cancer patients lack effective care. Opioids analgesics: availability, costs and access. Since 1999, there have been 12 different opioid analgesics available. According to the International Narcotics Control Board, the annual consumption of morphine is increasing.6,7 High prices place restrictions on the use of these drugs (Table 1). Although increasing competitiveness in the opioid market has led to a decrease in price, and even though some health systems partially cover the cost of commercial preparations, opioid drugs are still very expensive.7 As a result, fewer patients can afford the treatment than need it. Pursuant to the economic crisis of January 2002, a greater decrease in accessibility is possible because, even if their cost does not change, approximately 50% of the population has an average monthly income below U$S 200. Seventeen of 23 public hospitals providing
Vol. 24 No. 2 August 2002
Table 1 Opioid Availability in Argentina in 2001 Buprenorphine Codeine Dextropropoxyphene Hydrocodone Hydromorphone Fentanyl Pethidine IR Morphine SR Morphine Methadone Nalbuphine SR Oxycodone Tramadol
US$ 6 324a US$ 6 400a US$ 6 72 and 131a US$ 6 582a US$ 6 89a US$ 6 702a
aCost per month (daily dose: 180 mg equivalents of oral morphine) at the end of the year 2001 SR, sustained slow release; IR, immediate release
oncological assistance in Buenos Aires City had oral morphine by the year 2000, but only 5 of them had at least other recommended strong opioids to make rotation if it is necessary.5 Insufficient professional training. PC is still not part of the undergraduate curriculum. Health professionals acquire his/her PC knowledge and skills after graduation, generally in a combination of courses, seminars and conferences. This postgraduate learning relies mostly on reading material without clinical training. Insufficient public information. Subjects that refer to the end of life, and the available assistance options, are not frequently mentioned in the media.
The Future of Palliative Care We believe that in the near future, though not immediately, conditions will be right to guarantee a health care process intended to improve end-of-life care in Argentina. Difficulties are now identified, and we now see a willingness to solve them. Different people and institutions are working to achieve several goals. Care goals. • Increase PC access to the public through private and social institutions with a broader coverage. • Implement the National Standards for Organization and Operation in PC for referral/admittance of intermediate and high complexity PC teams. • Develop a list of drugs (vademecum; mostly potent opioid analgesics) that
Vol. 24 No. 2 August 2002
should be distributed free to patients lacking health coverage. Professional goals. • Recognition of PC teams in both the mainstream of medicine and the structure of public and private institutions. • Establish a licensing and certification system for PC caregivers by the Argentine Medical and Palliative Care Association (AAMyCP). • Establish a fee-paying system for the different disciplines related to PC. Education goals. • Systematic inclusion of PC in pre- and post-graduate curricula. Research goals. • Obtain reliable epidemiological data. • Compile information for future planning and monitoring the activity of existing programs.
Argentina
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Aspects without change include: • High cost of the usual drugs and present increase due to currency devaluation. • Infrequent provision by social plans and private sector. • Very low number of teams and specific beds is in relation to a population of 35 million. The latter aspects are a great challenge in the present national context of serious economic problems, with the logical repercussion in a health system that has historically evidenced grave deficiencies and inequities.
References 1. Argentina. In: La Salud en Las Américas. Eds Oficina Sanitaria Panamericana. Oficina Regional Organización Mundial de la Salud. Washington DC, EUA;1998; Vol II: 24–48.
To summarize the status of PC in Argentina, we finally will mention those aspects that are in constant progress and those that appear to be without change.
2. Wenk R, Bertolino M. Models for the delivery of palliative care in developing countries: The Argentine model. T39-50. In: Bruera E, Portenoy R, eds. Topics in Palliative Care, Vol 5. New York: Oxford University Press, 2001: 39–51.
Aspects in constant progress include:
3. Normas de Organización y Funcionamiento 934/01 del Ministerio de Salud Argentino. 2001.
• Increase in the demand for and availability of training at the postgraduate and graduate levels. • Existence of programs that allow training with clinical practice. • Existence of PC services with their own hospitalization facilities. • Increase of home care programs. • Good level of availability in opioids, though their accessibility is still low. • Government initiatives including standards for organization and operation of PC, incorporation of minimum obligatory health provisions, and work on diagnosis and treatment guides. • Plans for professional certification by the AAMYCP.
4. Wenk R, Marti G. Palliative care in Argentina: deep changes are necessary for its effective implementation. Palliat Med 1996;10: 263–264. 5. Bertolino M, Rodriguez A, Laje E, et al. Opioids Availability in public hospital that assist cancer patients in Buenos Aires. 18th International Conference of the International Society for Quality in Health Care. 2001, October. Buenos Aires, Argentina. 6. Joranson DE, Gilson AM, Nelson JM, Colleau SM. Disponibilidad de opioides para el alivio del dolor en cancer: puntos relevantes en America Latina (monografía). Division of Policy Studies; University of Wisconsin Pain Research Group/WHO Collaborating Center, Madison, Wisconsin. 1999. 7. Wenk R, Bertolino M, Pussetto J. High opioid costs in Argentina: an availability barrier that can be overcome. J Pain Symptom Manage 2000;20: 81–82.
Journal of Pain and Symptom Management
Vol. 24 No. 2 August 2002
Argentina: Palliative Care Status 2002 Roberto Wenk, MD and Mariela Bertolino, MD Argentine Program of Palliative Medicine-Fundación FEMEBA, Buenos Aires, Argentina
Introduction Half of Argentina’s 35 million inhabitants live in the urban areas scattered throughout the country’s 23 provinces. The health services comprise 3 providers: public services (50% of the population with 81,000 beds), mutuals or social plans (45%), and a private sector (5%). Health care development varies considerably, with areas of excellent medical facilities and others with insufficient basic primary care.1 At present, the country is undergoing a severe economic and social crisis, which has huge repercussions in the health system. The purpose of this paper is to describe the status of palliative care (PC) in Argentina. Much is known, but some information could be incomplete because there are no up-to-date national data.
patient-family unit does not receive help with its practical, social and emotional needs. If a patient does not “fit” into the available curative treatment, the chances are that he or she will be practically forsaken by the health system. At the San Nicolás Palliative Care Center, 146 advanced cancer patients were managed during the period of July 1999–July 2001. At the initial consultation, it was noted that, even though 66% had health benefits and 42% were in touch with their primary care physician, more than half (55%) had not undergone any symptomatic treatment and were suffering 6.5 2.6 (mean SD; range 1–11) different symptoms. The average pain intensity was 7 2 (range 2–10). This is applicable to what happens in most of our cities.
Palliative Care Development Situation of Patients with Advanced Incurable Diseases PC is not systematically recognized as a medical practice and is not included in health plans. Few public institutions offer it and prepaid or social health plans seldom accept it. As a general rule, this situation exposes patients with advanced incurable diseases to undertreatment or therapeutic methods that are ineffective or not adequate for their needs. This group of patients receives the conventional care now available in health institutions. In most cases, it is incomplete. Patients suffer from multiple uncontrolled symptoms and the
Address reprint requests to: Roberto Wenk, MD, Juncal 860, 1062 Buenos Aires, Argentina. © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
PC began to be offered in 1982. Our cultural and economic characteristics modeled its development in three consecutive stages:2 A. Horizontal. It works and expands “on surface” in the same level of motivation and dedication within the community and nongovernmental organizations (NGOs). In numerous cities, volunteers and professionals of different health disciplines care for the patient-family unit and establish links with the health net, the complexity of their activity depends on available resources. It has sustained development. B. Ascendant. Results obtained in (A) triggered activity in superior levels of organization in the community (i.e., municipalities, hospitals, universities) after captivating their authorities’ interest. People from teams initiated and developed in the community provide assistance and teaching at hospitals and universities. 0885-3924/02/$–see front matter PII S0885-3924(02)00444-X
Vol. 24 No. 2 August 2002
C. Descendent. Results obtained in (A) and (B) produced changes at the official organization level. The most important consequences due to health authorities’ interest in this issue are: 1. On August 22, 2000, the Ministry of Health and Social Activities approved by resolution 643/2000 the National Standards for Organization and Operation in PC, developed by its Medical Care Quality Guarantee Program in collaboration with different institutions.3 These standards require that the treatment unit (patient and family) is admitted to one of the different 3 levels and can shift between them according to suffering or impairment of quality of life. The differences between levels are established by (a) specific assistance goals, (b) team characteristics, (c) each discipline’s functions and its shared or specific activities, (d) its operation, (e) the criteria applied for referral among levels, (f) equipment, and (g) services and support institutions. 2. On October 25, 2000, the Ministry of Health and Social Activities approved the recognition of PC as a medical practice, its inclusion in the minimum obligatory health provisions, and its inclusion in health plans and medical health systems. This is the starting point of an automatic administrative process that will sequentially determine the recognition of PC as a medical practice and its inclusion in health plans and medical health systems.
Palliative Care Practice Almost all PC programs provide partial care, with variations related to their particular development: individual work, limited availability of teams, care in an institution or at home, presence or absence of specific facilities, etc. Economic restrictions and a health policy that places no emphasis on PC impede the availability of the components for a full PC program (24/7 care, in consulting room, at home, day hospital service, hospitalization). The characteristics of these programs are as follows: Patients. Most are cancer patients, but lately the spectrum increased with the inclusion of
Argentina
167
AIDS and other chronic and/or degenerative diseases. There are far more teams treating adults patients than those treating pediatric patients. Teams. Although there are only approximately 70–90 recognized active teams throughout the country, PC activity can be identified in every major and medium-sized city. • Disciplines. The teams can include two or more disciplines. All have a minimum of one MD that join with nurses, psychologists, social workers, pharmacists, volunteers, chaplains, depending on both the availability of professionals in the area and the patient’s clinical situation. Most teams comprise only two disciplines. • Dedication. Most teams include part-time professionals. Very few can dedicate fulltime work to PC because the remuneration does not encourage it; the bulk of their work is done in other fields. • Members’ earnings. Some team members are paid and some are volunteers; most groups have mixed personnel. Few health systems pay fees for PC services and most of the remunerated ones are not paid enough. In the public system, most of the professionals work without additional pay. • Development stage. Some teams are just on the project stages, others are developing, and still others (approximately 10–15), are fully implemented. There is an increase of professionals interested in creating new teams. • Teaching and research tasks. All teams perform internal teaching in their institution and frequently also outside teaching. Several training systems are already implemented: university or non-university courses, single or interdisciplinary, distance education system or with a heavy hourly practice. The diverse types of learning methods allow the professionals or volunteers to acquire or complete their education. The curriculum for oncology at different universities includes specific PC modules. Research is in the initial phases, but several teams recognize the importance and need of producing local data. • Assistance. Outpatient consultations are available in all programs. Day care services
168
Wenk and Bertolino
are provided in few institutions; this area is still in the development stages. Home care is practically non-existent in the public system, but has a wider development in the private sector and social organizations. Only two public institutions have PC-specific areas for in-patients (PC units), with a total of 12 beds for the country. Institutions. Public and university hospitals, private clinics and NGOs.
Barriers to Palliative Care Implementation Distribution of resources. Most of the human and material resources in the health care system are dedicated to curative treatments. PC as a medical practice is not yet included in the health plans: A 1996 survey shows that less than 10% of both prepaid and social health plans will pay for PC and a 1998 poll revealed that only 7 out of 33 public hospitals in Buenos Aires, have active PC teams.4–5 Once again, San Nicolas can be used as an example: A city with a population of 150,000, with 1 public hospital and 3 private clinics, 450 beds, over 400 doctors, 2 cardiac surgery services, 2 hemodynamia teams, 4 CAT scans, 3 oncology teams, 3 ICUs, etc. Despite this oversupply of health resources, most advanced cancer patients lack effective care. Opioids analgesics: availability, costs and access. Since 1999, there have been 12 different opioid analgesics available. According to the International Narcotics Control Board, the annual consumption of morphine is increasing.6,7 High prices place restrictions on the use of these drugs (Table 1). Although increasing competitiveness in the opioid market has led to a decrease in price, and even though some health systems partially cover the cost of commercial preparations, opioid drugs are still very expensive.7 As a result, fewer patients can afford the treatment than need it. Pursuant to the economic crisis of January 2002, a greater decrease in accessibility is possible because, even if their cost does not change, approximately 50% of the population has an average monthly income below U$S 200. Seventeen of 23 public hospitals providing
Vol. 24 No. 2 August 2002
Table 1 Opioid Availability in Argentina in 2001 Buprenorphine Codeine Dextropropoxyphene Hydrocodone Hydromorphone Fentanyl Pethidine IR Morphine SR Morphine Methadone Nalbuphine SR Oxycodone Tramadol
US$ 6 324a US$ 6 400a US$ 6 72 and 131a US$ 6 582a US$ 6 89a US$ 6 702a
aCost per month (daily dose: 180 mg equivalents of oral morphine) at the end of the year 2001 SR, sustained slow release; IR, immediate release
oncological assistance in Buenos Aires City had oral morphine by the year 2000, but only 5 of them had at least other recommended strong opioids to make rotation if it is necessary.5 Insufficient professional training. PC is still not part of the undergraduate curriculum. Health professionals acquire his/her PC knowledge and skills after graduation, generally in a combination of courses, seminars and conferences. This postgraduate learning relies mostly on reading material without clinical training. Insufficient public information. Subjects that refer to the end of life, and the available assistance options, are not frequently mentioned in the media.
The Future of Palliative Care We believe that in the near future, though not immediately, conditions will be right to guarantee a health care process intended to improve end-of-life care in Argentina. Difficulties are now identified, and we now see a willingness to solve them. Different people and institutions are working to achieve several goals. Care goals. • Increase PC access to the public through private and social institutions with a broader coverage. • Implement the National Standards for Organization and Operation in PC for referral/admittance of intermediate and high complexity PC teams. • Develop a list of drugs (vademecum; mostly potent opioid analgesics) that
Vol. 24 No. 2 August 2002
should be distributed free to patients lacking health coverage. Professional goals. • Recognition of PC teams in both the mainstream of medicine and the structure of public and private institutions. • Establish a licensing and certification system for PC caregivers by the Argentine Medical and Palliative Care Association (AAMyCP). • Establish a fee-paying system for the different disciplines related to PC. Education goals. • Systematic inclusion of PC in pre- and post-graduate curricula. Research goals. • Obtain reliable epidemiological data. • Compile information for future planning and monitoring the activity of existing programs.
Argentina
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Aspects without change include: • High cost of the usual drugs and present increase due to currency devaluation. • Infrequent provision by social plans and private sector. • Very low number of teams and specific beds is in relation to a population of 35 million. The latter aspects are a great challenge in the present national context of serious economic problems, with the logical repercussion in a health system that has historically evidenced grave deficiencies and inequities.
References 1. Argentina. In: La Salud en Las Américas. Eds Oficina Sanitaria Panamericana. Oficina Regional Organización Mundial de la Salud. Washington DC, EUA;1998; Vol II: 24–48.
To summarize the status of PC in Argentina, we finally will mention those aspects that are in constant progress and those that appear to be without change.
2. Wenk R, Bertolino M. Models for the delivery of palliative care in developing countries: The Argentine model. T39-50. In: Bruera E, Portenoy R, eds. Topics in Palliative Care, Vol 5. New York: Oxford University Press, 2001: 39–51.
Aspects in constant progress include:
3. Normas de Organización y Funcionamiento 934/01 del Ministerio de Salud Argentino. 2001.
• Increase in the demand for and availability of training at the postgraduate and graduate levels. • Existence of programs that allow training with clinical practice. • Existence of PC services with their own hospitalization facilities. • Increase of home care programs. • Good level of availability in opioids, though their accessibility is still low. • Government initiatives including standards for organization and operation of PC, incorporation of minimum obligatory health provisions, and work on diagnosis and treatment guides. • Plans for professional certification by the AAMYCP.
4. Wenk R, Marti G. Palliative care in Argentina: deep changes are necessary for its effective implementation. Palliat Med 1996;10: 263–264. 5. Bertolino M, Rodriguez A, Laje E, et al. Opioids Availability in public hospital that assist cancer patients in Buenos Aires. 18th International Conference of the International Society for Quality in Health Care. 2001, October. Buenos Aires, Argentina. 6. Joranson DE, Gilson AM, Nelson JM, Colleau SM. Disponibilidad de opioides para el alivio del dolor en cancer: puntos relevantes en America Latina (monografía). Division of Policy Studies; University of Wisconsin Pain Research Group/WHO Collaborating Center, Madison, Wisconsin. 1999. 7. Wenk R, Bertolino M, Pussetto J. High opioid costs in Argentina: an availability barrier that can be overcome. J Pain Symptom Manage 2000;20: 81–82.