Dr Emmanuel Luyirika assesses the opportunities presented by the WHA resolutions for palliative care in Africa

“Palliative Care is everyone’s business” was the theme for the 4th Kenya   National Palliative Care Conference hosted in Nairobi in Nov 2014.  Delegates were drawn from many countries in the region, from Kenya to Malawi and from Rwanda to Uganda.

In his keynote address, “Strengthening of Palliative Care as a component of comprehensive care throughout the life course,” Dr Emmanuel Luyirika, Executive Director of the African Palliative Care Association, reviewed the situation in Africa in the light of the roles and responsibilities identified within the WHA Palliative Care Resolution.

The resolution defines palliative care as “an approach that improves the quality of life of patients (adults and children) and their families who are facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual”

What is unique and innovative in the resolution?  Dr Luyirika identified four important areas;

  1. It focuses on health systems rather than specific diseases
  2. It urges palliative care integration into health worker training and education at all levels
  3. It highlights health workers in oncology, paediatrics, geriatrics and internal medicine for in-service training among others
  4. It urges governments to fund palliative care

He went on to draw attention to the Roles and Responsibilities in the resolution which fall on all stakeholders from WHO member states to Training and Education institutions, Civil Society and patients’ organisations, The WHO through its Director General, Other international agencies such as UNICEF, INCB and Care givers in general.

Roles and accountability

  • The Resolution mentions nine roles for Members states and calls on them to develop and implement palliative care policies to support the comprehensive strengthening of health systems to integrate evidence-based, cost-effective and equitable palliative care services in the continuum of care, across all levels.

Under this there is an imperative to ensure adequate domestic funding and human resources are in place for implementation of all aspects of palliative care service delivery. Steps are to be taken to educate, train and equip caregivers and health workers at every level of care provision for patients with life-threatening illnesses. Collaborative action to ensure adequate supply of essential medicines in palliative care and the avoidance of shortages is to be promoted. National and Local legislation and policies for controlled medicines are to be reviewed with reference to WHO policy guidelines. National essential medicines lists may need to be updated in the light of the recent addition of sections on pain and palliative care medicines to the WHO model list of essential medicines.

Members are to foster partnerships between governments and civil society, including patients’ organizations, to support, as appropriate, the provision of services for patients requiring palliative care.

WHO holds all member states accountable and expects them to implement and monitor palliative care actions included in WHO’s global action plan for the prevention and control of NCDs 2013–2020

  • There is a clear recognition in the WHA resolution of the vital role of Civil Society and Dr Luyirika highlighted the endorsement of partnerships between governments and civil society organisations including NGOs to support service provision in palliative care.

 

  • The role of the Director General of WHO was helpfully described in some detail and summarised as;
  1. to ensure that palliative care is an integral component of all relevant global disease control and health system plans,
  2. to develop evidence-based guidelines and tools on palliation in adults and children and integration of palliative care into national health systems, across disease groups and levels of care
  3. to support Member States in reviewing and improving national legislation and policies with the objective of ensuring balance between the prevention of misuse and appropriate access to controlled medicines and explore ways to increase the availability and accessibility of medicines used in palliative care
  4. to work with the International Narcotics Control Board, the United Nations Office on Drugs and Crime, UNICEF and health ministries and other relevant authorities to promote the availability and balanced control of controlled medicines.
  5. to monitor and evaluate the global situation of palliative care in collaboration with Member States and international partners while encouraging improved funding and research.

Reporting responsibilities

Countries have a responsibility to have reported to WHO by 2016 which means the process of data collection should have begun by now if countries are to report in time for the WHA.  The Director General of WHO will report back to the WHA in 2016.

PALLIATIVE CARE SITUATION IN AFRICADSC_0013

Dr Luyirika spoke compellingly of the huge need for better provision of Palliative Care in Africa.  With the exception of South Africa and a few other countries, there is poor coverage of Palliative Care provision in Africa.  Even in countries where palliative care is available less than 10% of patients receive adequate care.

Policies, strategies and guidelines are at various stages of development in countries such as Zimbabwe, Botswana, Malawi, Tanzania and Uganda.  He drew attention to the success of nurse prescription in Uganda and stand-alone PC policies in Rwanda, Swaziland and Mozambique.

Formal palliative care education courses are run in SA, Uganda, Kenya and Tanzania leaving a considerable distance to travel before palliative care education extends across the continent.  However, health workers from other African countries are benefitting from palliative care courses in Uganda and South Africa.  Encouragingly progress is evident in Namibia, Botswana, Swaziland, Mozambique, Malawi and Zambia.  Research training and mentoring have been a focus in the THET Integrate project with trainings and support in each of the project countries; Kenya, Rwanda, Uganda and Zambia.

Legal and policy obstacles to Opioid availability remain one of the major challenges to providing appropriate palliative care with only 12 out of 50 countries having a degree of support from APCA and partners to improve medicine availability in 2014. Uganda has ring-fenced money for palliative care medicines particularly oral morphine.  Kenya is reported to have included palliative care in the current budget and others such as Rwanda and Namibia are including opioids in purchases.

Step by step significant inroads are being made across the continent and in the year 2013-2014 APCA working with other partners, supported 58 facilities in 14 countries to improve palliative care service delivery. This included the 12 hospitals and their communities in the THET Integrate project.

The WHA resolutions are timely, presenting considerable opportunities for palliative care across the African continent –  Opportunities to improve human resource development for palliative care,  opportunities to ensure palliative care sustainability by campaigning for its inclusion in national budgets, opportunities to work with WHO to develop guidelines for every African nation, opportunities to lead more research in palliative care, opportunities for collaboration between governments and civil society organisations  and opportunities to contribute to universal healthcare coverage.

APCA’s vision is to promote access to all who need palliative care in Africa. To achieve this they will continue to work with governments to implement the WHA Resolution at policy and funding levels, to encourage civil society organisations to work with governments in implementing the Resolution and to promote and facilitate reporting mechanisms to the Director General of WHO.