Palliative Care in Southern Africa

In many African countries, palliative care is not yet integrated into national policies so public health access is not available to the majority of those who require palliative care. The African Palliative Care Association (APCA) embarked on a project that aimed to review national legislation and policy documents and implementation strategies across ten African countries to identify and assess ways to support palliative care scale-up at the national level.

Author

October 10th, 2012

In many African countries, palliative care is not yet integrated into national policies so public health access is not available to the majority of those who require palliative care. The African Palliative Care Association (APCA) embarked on a project that aimed to review national legislation and policy documents and implementation strategies across ten African countries to identify and assess ways to support palliative care scale-up at the national level.

Funded by the Open Society Foundations and the Open Society Initiative for Southern Africa (OSISA), this review - Palliative Care in Southern Africa - Review of current policies and opportunities for scaling up care - covered Angola, Botswana, the Democratic Republic of Congo (DRC), Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe

The review was undertaken using a review tool that was developed using existing information on policy, gender issues and palliative care. However, because there is little information on the relationship between gender and palliative care, a comprehensive literature review was undertaken to analyse this relationship and to inform the development of a gender review framework for the project. In addition, a rapid appraisal was conducted among patients and caregivers in Zambia and Zimbabwe.

The review of these documents aimed to identify opportunities, gaps, strengths and gender issues that affect the integration of palliative care within policy, and assess the extent of integration. Therefore, it was important to develop a tool that would enable APCA to capture this information in a standard format. The primary aim of the tool was to enable reviewers to assess and review the type of language provided in each policy, and whether the language could be strengthened in favour of palliative care provision.

The review found an overall lack of inclusion of palliative care in policy documents. For most countries in the region, there is no mention of palliative care as an important aspect of care for people with life-threatening illnesses. In Zimbabwe, only one of the documents specifically addresses the need for palliative care. The World Health Organization (WHO) definition is not mentioned in any of documents that were reviewed.

In Malawi, palliative care is given low recognition, and only one of the documents mentions palliative care (without any proper definition). In the DRC, the reviewed documents focus predominantly on HIV and AIDS care and associated services. While home-based care and holistic care are mentioned, these are not based on the WHO definition of palliative care and pain management does not feature.

Namibia is making strides in addressing the need for palliative care, and has embarked on integrating palliative care into the overall national health infrastructure, especially in more recent national documents. However, there is a place for palliative care in all documents related to the care and protection of patients with life-threatening conditions and their families.

In general, all the documents from the ten countries would be suitable for varying levels of palliative care integration. A general but clear definition needs to be provided, along with relevant insertion of palliative care strategies as appropriate. It is important at all levels to emphasise that the family and the patient are the unit of care. Clear policy statements about the right to palliative care and pain control would reinforce the role of palliative care in mainstream health systems.

With regard to gender issues, all the documents could benefit from a broader understanding of gender, including sexual minorities. A greater emphasis on the role of men as caregivers would be appropriate. None of the documents addresses domestic violence in any detail, although some do refer to the issue.

In Angola, DRC, Lesotho, Malawi, Namibia, Swaziland and Zambia, opioids are not mentioned in much detail in the documents. The fact that pain relief is a basic human right and that unrelieved pain greatly impacts on quality of life means that there is a need to address the issue of availability and accessibility of opioids (particularly oral morphine), and to define how these medicines should be controlled across all levels of health care. In Mozambique, opioids are also not addressed although there is a commitment to international human rights and best practice, which can assist the integration of palliative care, pain management, availability of opioids and their usage. In Botswana, all the reviewed documents mention morphine, but there is no evidence of laws and regulations regarding importation, transportation, prescription or storage.

All the reviewed documents fail to address the issue of opioid use adequately, and do not recognise the ethics of pain-relief. A statement on the right to a pain-free death would inform ethical considerations. There is minimal acknowledgement of ethics, human rights, anti-discrimination issues and confidentiality. The documents would benefit from linking human rights in general to the right to health care (including pain-control) in particular.

Given the above findings, APCA makes the following recommendations:

  • Palliative care (as defined by WHO) should be integrated into policies and documents as appropriate, referencing the needs of women, children, vulnerable populations, minorities and all who require a holistic approach to living with life-threatening illnesses;
  • A commitment to human rights needs to be explicit in policy and programme documents to make clear the link between the promotion of strategies and activities, and the daily lives of individual people;
  • Safe and consistent opioid supplies need to be guaranteed – the relevant policies should detail the steps taken by the authority concerned (the national competent authority) for procurement and supply of pain-relieving drugs, particularly oral morphine, which might entail a review of the current rules and regulations regarding the use of opioids to ensure that there is increased availability and access to such medicines for patients who need them;
  • The ministry of health in each country should be encouraged to consider developing national guidelines for the use of opioids, in line with international recommendations, to ensure the safe and effective use of opioids; and,
  • An expanded understanding of gender issues to embrace sexual minorities is imperative if the HIV epidemic is to be addressed comprehensively, while risk behaviours of people who have concurrent and multiple sexual partners need to be debated without prejudice or judgement so that all people at risk are able to access care.

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