As we know, the cancer care continuum moves all the way, right from prevention to early diagnosis, treatment, palliation and even rehabilitation. So palliative care is right in there to improve the quality of life of patients who have been given a cancer diagnosis, whether they are to be cured or not to be cured. According to the World Health Organisation recommendation we should provide it from the moment of diagnosis. It is therefore important that we develop mechanisms that can ensure that patients get access to palliative care when they need it, where they need it and in very culturally sensitive approaches that bring about the quality of life for those patients who have cancer.

Is this difficult to achieve in such a vast continent like Africa?

Yes, it’s quite a difficult thing to do in Africa. Different countries in Africa are at different levels of development of palliative care, whether it’s policy, access to palliative care medicines, education or even the actual implementation of the palliative care programmes. The other difficulty in Africa is that you have such a diverse continent – you have Anglophone countries, you have Francophone countries, you have Lusophone, or Portuguese speaking, countries and then you have the Arabic speaking countries in the north. In each of those regions different factors obtain that affect access to palliative care as a service and controlled medicines that are used in palliative care in particular. At the moment we are seeing more development in the East and Southern Africa region in terms of access to palliative care for cancer patients compared to either West or North Africa. You see more development in the Anglophone countries compared to the Francophone or Portuguese speaking countries. Therefore one has to work around all the issues and ensure that patients, irrespective of the language region where they’re from or the geographic positioning, they’re able to access care. But we are still coming from a very low coverage of palliative care at a national level in most of the African countries.

Is access to opioids still a problem?

Opioid access is a major issue, even countries where you think we’ve made some progress if you look at the amount of opioids that they import and what that translates into in terms of coverage I think the top country in Africa is about 50%. They’re importing opioids that can cover about 50% of the need and all the other countries, apart from South Africa and maybe Tunisia, according to the most recent Lancet commission report fall below the 20%. Even in a country like Uganda where we think we’ve made good progress the amount of opioids that we import can only cover about 11% of the need. That, therefore, calls for more action to ensure that we improve access to opioids for cancer patients who need palliative care.

Is this just a financial issue?

It’s more than financial; the opioids themselves, especially the oral morphine that is used in much of Africa, is actually a very cheap medicine but the issue around regulations and restrictions, issues around prescription, because in many of the countries even when you have the opioids they can only be prescribed by medical officers or physicians. As you know, the doctor-patient ratio or doctor-population ratio in most of the African countries is very low so by the time you get a doctor to prescribe for you the opioids you may actually be dead. Therefore we need to look at other possibilities like having other non-physicians prescribe opioids, like nurses, well-trained nurses to prescribe opioids, it has happened in Uganda and it’s something that we must look at in other countries because you have more nurses than doctors and they’re very well trained and they’re very trainable as well. So you can use that cadre of health workers to ensure that there is improved access.

Any other important points to mention?

As a continent we need to ensure that we improve the policy frameworks around palliative care, that we improve access to palliative care education for health workers. We need to ensure that we invest in palliative care research so that we develop very appropriate models of care delivery in countries. We need to improve on the implementation in countries and ensure that we are able to cover patients wherever they are. We worked on an African palliative care atlas last year which was launched this year and we’ve actually shared it at this conference and it shows that different countries in Africa are at different levels. In terms of policy they have included some palliative care in various documents like the cancer control plan, the HIV plans and even standalone palliative care plans. Some have moved from having it in plans to actual implementation but many are yet to do that. Then, in terms of training and education we also have fewer countries where you can ensure that there is palliative care education and training integrated into curricula of health workers. Then you have the whole issue around the prescribers. Again, that’s another issue that is affecting access and whether the patients are accessed in their home using a home-based care approach or they can only get the service within a hospital facility alone.

So there are quite a number of things that still need to be improved upon but we are moving in the right direction, the only problem is the pace. In some of the countries and some of the regions the pace is slow. Then another very critical issue is funding for palliative care in Africa. In the past people leveraged HIV money to invest into palliative care ventures. That has now dried up and much of the cancer funding as well does not adequately cover the palliative care need. Therefore governments must invest in palliative care as a modality that needs to be developed in Africa, given the fact that even more than 80% of our cancer patients present at a time when they desperately need palliative care.