Barriers to palliative care delivery
APCA and other champions of palliative care in Africa face a set of challenges specific to the continent. But by identifying them and learning as much about them as possible, we can develop strategies for palliative care delivery that can overcome them.
Government national health policies
Many governments remain unaware of and uncommitted to delivering palliative care services, instead focusing scarce resources on curable diseases. Cancer treatment in particular is not prioritised, and there’s an absence of national palliative care policies in the majority of African countries. Even where there is interest, a lack of funding remains constant.
Essential medicines policy
The WHO urges African governments to institute policies on the importation and use of drugs for effective pain and symptom management (including opioids), so everyone can access affordable and effective medication. Yet many medicines remain unavailable and pain is unacceptably under-treated among children and adults. In most of Africa, legislation restricts the prescribing of opioids to doctors, severely limiting its availability given the continent’s low doctor-patient ratio and the predominantly non-facility based health care in rural areas.
There is a variety of training courses in Africa, from short certificate courses to diplomas and undergraduate and masters’ level degrees. But despite the WHO 2004 recommendation that governments include palliative care in training curricula for health workers at all levels, its integration into higher learning is not widespread in Africa, resulting in a severe shortage of palliative care professionals. Clinicians are often unaware of how to assess and treat pain, and ‘opiophobia’ is rife (fear of addiction and that prescribers will be vulnerable to prosecution). Palliative care education needs to target diverse audiences (including policy makers and the general public) to increase awareness and change attitudes.
Negligible levels of M&E and research
Despite powerful empirical evidence of the benefits of palliative care in Africa, there’s a lack of formal evidence from rigorous research, and of Monitoring and Evaluation (M&E) of service delivery. This research is needed to prove how palliative care transforms lives and communities, to underpin advocacy and education.
Africa’s low urbanisation means services often need to be provided to low-density populations across vast rural areas (Namibia averages two people per km2; Sudan’s population is 80 per cent rural or nomadic). Many health professionals prefer to work in urban areas, so rural health provision is often left to community- and home-based volunteers, able to deliver care that is only supportive in nature.
Poor public awareness and understanding
There exists a strong lack of public awareness about palliative care – most people haven’t heard of it, or if they have, understanding it as an end-of-life intervention needed only after curative treatment is stopped. This belief persists despite powerful evidence that patients need pain and symptom management and psychosocial care throughout their disease. There are also cultural taboos around death and the disclosure of diagnosis. Many people with HIV/AIDS and cancer delay seeking medical help, through fear of stigma and ignorance of symptoms and available treatment.
The right to palliative care?
Africa suffers from a lack of consensus that (or even consideration whether) palliative care is a basic human right – even though powerful philosophical and legal arguments have been made to support the case that it is (as is APCA’s firm conviction).
In 2002, palliative care donors and workers in Africa recognised that the continent’s pioneering islands of palliative care excellence were doing an impressive job, but that it was impossible for them to reach vast majority of Africa’s people – both in terms of their own capacity and of working outside national health systems. Something had to be done. That’s where APCA came in.