Cooperation program for hematology-oncology development in the public health care system in La Paz, Bolivia: a bilateral initiative with a public center in Montevideo, Uruguay

Bolivia is a developing country with ∼11 million inhabitants and is constantly growing. In recent years, Bolivia has experienced significant political, social, and economic changes.

Positive changes in health were also achieved, mainly focused on prevalent diseases. However, in hematology, there are still many challenges, including:

• difficulties with public access to adequate diagnosis and treatment of hematological diseases;

• lack of specific health policies for hematological diseases;

• barriers to access for specific drugs; and

• lack of a hematopoietic stem cell transplantation (HSCT) center for public access.

The factors involved are predominantly economic, structural, political, and social.

The magnitude of the problems identified led to a collaborative effort between 2 institutions: the Hematology and Hematopoietic Stem Cell Transplant Department of Maciel Hospital (Montevideo, Uruguay) and the Hematology Department of the Hospital de Especialidades Materno Infantil (La Paz, Bolivia) (Figure 1). This action was considered necessary in order to overcome several obstacles, based on the experience of a greater complexity center. The initiative started officially in September of 2016.

• Contribute to the scientific development of Bolivia and strengthen international ties.

• Improve diagnostic and therapeutic strategies in hematology, which will result in better quality of life for patients.

• Establish a public access hematopoietic stem cell transplantation unit, adapted to the needs of the population, based on the experience of the Maciel Hospital.

• Improve the professional development of personnel related to hematology.

• Create policies to achieve unrestricted access to the treatment of hematological diseases for the Bolivian population.

The Hematology Department of Hospital de Especialidades Materno Infantil is located in the city of La Paz (Figure 2), is part of the Caja Nacional de Salud (social security) of the public system, and provides care to ∼1 million people, more than half of whom are adults. This institution is considered a reference center for hematological diseases to other Bolivian cities. The Hematology Department of Hospital de Especialidades Materno Infantil is the first and only training center for hematology specialists in Bolivia.

Hospital Maciel in Montevideo, Uruguay (Figure 3), is a fourth-level School Hospital of the National Network of Public Health Institutions integrated into the National Health Care System.

The Hematology and Hematopoietic Stem Cell Transplant Department is a reference center for patients with chronic and acute hematological malignancies from the National Public Hematological Network. It was established as an intensive hematological unit and receives patients for induction and treatment of acute leukemia and for high-intensive treatments in lymphoma and myeloma patients. It was built as an Institute of High Technology to perform all the stem cell and bone marrow transplantation modalities. It is a training center for residents in hematology of the National Residence Program in Uruguay and for Latin American hematologists in the field of HSCT in the setting of the Latin American Visitor Training Program (LA-VTP) of American Society of Hematology.

Hematology resident training: since 2016. Duration: 3 months.

Key elements of resident training:

• health care activities of hematological patients (inpatient and outpatient);

• discussion of complex clinical cases;

• participation in scheduled HSCT meetings;

• presence and participation in the entire HSCT process: pretransplantation evaluation, mobilization, processing, and infusion of hematopoietic stem cells;

• visits to the laboratories of histocompatibility, flow cytometry, and cytogenetics;

• development of a monograph related to the HSCT field, which will be useful for the global approach of the project; and

• participation in continuing medical education activities.

Training for nurses: began in 2017. Duration: 2 months.

Main aspects of nursing training:

• comprehensive nursing management of critical hematologic patients and pathways of all HSCT procedures; and

• preparation, division, and administration of chemotherapeutic drugs and monoclonal antibodies (in the chemotherapy reconstitution unit).

These activities are carried out through monthly teleconferences, with a programmed schedule. A particular case is presented and then discussed and updated

• treatment of relapsed acute lymphoblastic leukemia in adults;

• update on the diagnosis and treatment of T-cell lymphomas (the T-Cell Project);

• progress in the diagnosis and treatment of lymphomas, carried out during the visit of French experts to the Hospital Maciel, through live broadcast to La Paz;

• therapeutic aspects of acute promyelocytic leukemia: frontline and relapsed treatment (Pethema and International Consortium on Acute Promyelocytic Leukemia/ASH protocols); and

• treatment of relapsed and refractory multiple myeloma.

• The host department director visited the center in La Paz during his participation in an academic congress.

• The purpose of this visit was to evaluate the infrastructure for the adaptation and construction of the unit of critical hematology and HSCT.

• The initial evaluation was expressed in a monograph by one of the trained residents. This reflects the possibility of progressively developing the HSCT program adapted to the conditions and needs of the country.

• This is an essential resource for the diagnosis and follow-up of hematological malignancies and for the HSCT program.

• The Hospital Maciel will provide the necessary training in flow cytometry and immunophenotypic studies for this effect.

• This project has been supported by the institutional authorities of both countries, particularly the local institutions of Caja Nacional de Salud in La Paz.

• The home center is already working on infrastructure and facilities, human resources, and the progressive implementation of equipment.

• Meanwhile, personnel training, elaboration of treatment protocols and procedures, and implementation of necessary logistical resources will be continued.

• The transplantation activity will begin progressively, starting with autologous HSCT in lymphoproliferative diseases followed by the implementation of more complex procedures.

• Generate expectations for the progress of hematology in La Paz, promoting the involvement and stimulating the leadership of young hematologists, to improve hematologic health care for the population.

• These initiatives can be implemented in other areas of health where cooperative work can have a positive impact on the population.

• Engage in projects of bilateral cooperation of social scope.

• Develop a spirit of solidarity and teaching, with bilateral benefits, exchanging experiences with societies that share the same difficulties with the intention to overcome obstacles to better improve the quality of life of their population with hematological malignancies.

• Establish an HSCT center in the Hospital de Especialidades Materno Infantil of La Paz, with the incorporation of strategies and technology in a progressive way and adapted to realities and possibilities in Bolivia.

• Continue the cooperation program and extend it progressively to other areas, such as the diagnosis of hematological malignancies (pathological anatomy, immunohistochemistry, conventional cytogenetics/fluorescence in situ hybridization, flow cytometry, and molecular biology).

• Promoting the involvement of the authorities in order to obtain the necessary means to combat disparities in the availability and accessibility of high-cost drugs that represent the current treatment of hematological malignancies.

• Share alternative routes adopted to facilitate such access.

• Coordinate and promote clinical investigation and research between both institutions.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Nelson Nina, Servicio de Hematología, Hospital Santa Bárbara, Destacamento 111, Sucre, Bolivia; e-mail: nelson_ninag@outlook.com.