Scaling up Palliative Care Services Across Government Hospitals in Tanzania

Palliative Care workshop participants.

Background

Tanzania, like other sub-Saharian African countries, is faced with a major challenge in meeting the health needs of its people. The HIV/AIDS pandemic has caused a great deal of physical, emotional and psychological suffering among its victims as well to their families. This was confirmed by a WHO situation analysis and needs assessment report published in 2002. The number of cancer cases has been steadily increasing in the course of the last decade, and HIV/AIDS-related cancers, such as Kaposi sarcoma, have become the most frequent malignancies in the only cancer center in Tanzania, namely, Ocean Road Cancer Institute (ORCI). Owing to adoption of a Western lifestyle, especially among the middle classes, diseases such as diabetes, hypertension, arthritis, etc., are also increasing at an alarming rate, causing additional human suffering which, given the limited resources for health care in Tanzania, seems to have no end in sight. Health spending per person is still staggeringly low at 10 USD per year. But in spite of the increase in non-communicable diseases, malaria and other infectious diseases, along with maternal and infant mortality, remain the government’s highest health priorities.

In 1999, the government realized that he could no longer afford to provide hospital-based end-of-life care and developed home-base care programs. This did reduce hospital expenses and, in theory, should have permitted patients to spend the terminal phases of their diseases surrounded by their loved ones, but most patients did not die at home as per their wishes. When pain and other distressing symptoms became unbearable and uncontrolled by simple medication such as paracetamol - all that was available at home - they were rushed to hospital in order to try to alleviate their suffering. This rarely helped because hospital staff lacked knowledge of palliative care, such that many patients died in agony. In addition, with 95% of the oral morphine consumed in Tanzania being used at ORCI, one can only imagine how many patients in the country faced death without adequate pain control. Undignified death leads to greater difficulties among the bereaved family members, and in the absence of training in palliative care, hospital staff often avoid the dying patient because they feel they cannot help, leaving the patient isolated and worse off then had he or she remained at home.

ORCI, being a government institution and the first to establish palliative care (in 1995), felt that it could use its experience to scale up palliative care in the country in an attempt to alleviate the suffering of so many patients and families. We joined hands with our INCTR colleagues, with whom ORCI has a long history of collaboration in a number of areas including Burkitt lymphoma therapy and cancer prevention. INCTR-PAX, INCTR’s palliative care program, is also working with the Programme of Action in Cancer Therapy (PACT) of the International Atomic Energy Agency (IAEA) to build a comprehensive cancer control program in Tanzania, of which palliative care is an important component. After a memorandum of understanding was signed by the involved parties, the existing palliative care office at ORCI was furnished and a project secretary was recruited in February. I was recruited as a part-time Program Director to help realize the aims and objectives of the project. One of the objectives was to establish a center of excellence in palliative care at ORCI over three years, to accredit this program as well as persons trained in palliative care. Plans are also underway to build separate palliative care wards for adults and children. The development of existing capacity in palliative care (both hospital and home-based) had been partly supported in the past by the International Association of Hospices and Palliative Care (IAHPC) and the Diana, Princess of Wales Memorial Fund. This had already resulted in the palliative care resources at ORCI being greater than those at all other centers in the country combined.

ORCI/INCTR Approach

Our approach is based on the World Health Organization Foundation Measures of palliative care, namely education, drug availability (particularly oral morphine) and advocacy. Our target area to begin with is government hospitals, including district, regional and referral hospitals, countrywide. There are about 160 of these targeted hospitals and we estimated that between 1.5 and 2 million USD would be required over three years for training, advocacy and opioid procurement and distribution to all participating hospitals in the seven existing administrative zones.

Advocacy

With regard to advocacy, we planned to hold a number of sensitization workshops for the heads of these respective government health facilities to alert them to the urgent need for palliative care and to urge them to form and support palliative care teams in their hospitals. Other planned workshops will be held for the media, business communities and civil society. Pediatric palliative care, which has not been included in the past, will also be developed through building a separate pediatric palliative care ward and holding a special workshop for pediatricians and others involved in caring for children affected with HIV/AIDS and cancer. This workshop is planned for Jan/Feb 2008. The INCTR/ORCI role would be to equip the team members with appropriate palliative care knowledge and skills through training and, equally important, continued mentorship. So far one sensitization workshop in the Eastern zone of the country has been successfully conducted and a task force was formed to ensure that the actions decided upon in the workshop are implemented. Another workshop for the Southern zone will be conducted in July 2007.

Training

It was agreed that training would take place in six week training courses in palliative care, held at ORCI, and delivered to the palliative care teams appointed by the hospital directors. Each zone, which normally comprises three to four administrative regions, each including approximately 15 district and regional hospitals, is expected to nominate about 45-50 trainees for the course, including nurses, clinicians, social workers, pharmacists and others. Training curricula and most of the educational tools have been prepared, although funds are needed to initiate the courses. The aim is to conduct three such training courses a year. If this succeeds, in three years over 400 persons, countrywide, will have been trained and palliative care teams established in all government hospitals down to the district level. In 2006 nurses working in home-based care programs in the Kinondoni municipality of Dar es Salaam were intensively trained in a one week course which was supported by the Diana, Princess of Wales Memorial Fund. In March 2007, 33 heads of health facilities in the same municipality will attend a similar course. Plans are at an advanced stage to procure oral morphine for these facilities.

Drug availability

ORCI/INCTR/IAEA-PACT initiatives in Tanzania have been generously supported by the Open Society Institute (OSI).

Our initiatives are intended to make oral morphine available initially in all government hospitals while simultaneously raising awareness of members of health professionals, policy makers and other relevant stakeholders in order to address barriers to its use. We do not underestimate the size of this challenge.

Strengths and weaknesses

ORCI, being a government facility, enjoys good relations with the public and policy makers at all levels. In addition it was the first hospital to establish a palliative care unit over 10 years ago and the first and only one allowed to import oral morphine in the country since 2002. Our Executive Director and the Chairman of the Board of Trustees are appointed by the Head of State. This puts us in a unique position to pursue this program at a national level. As the Director General of Medical Services told the PAX team members at a recent visit to the Health Ministry, ORCI is the entry point of palliative care policy and related matters in the country.

Our primary challenge is that palliative care in the country is in its infancy and still dependent on donors. It will be important to ensure that all stakeholders, including NGOs work in a coordinated fashion and that support provided fosters their collaboration. We hope that the donor community will support us in this noble work of making palliative care available and accessible such that the unnecessary suffering endured by our patients can be prevented. Tanzania provides an opportunity to demonstrate that palliative care donor communities worldwide, as well as organizations such as INCTR and PACT, can join hands, and in doing so, make a real difference.

Msemo B. Diwani,
Director ORCI/INCTR PAX Program,
Dar-Es-Salaam, Tanzania