Perspectives In Palliative Care In Tanzania [Новость добавлена - 11.12.2008]

Ward Units at Ocean Road Cancer Institute.

Tanzania, in East Africa, is one of the least developed countries in the world. In 2002, it had a population of 36 million people and an annual population growth rate of 2.4% per annum, although this is expected to fall. In the same year, the life expectancy at birth was 43.5 years, and the Gross Domestic Product per capita for Tanzania, US$580 (purchasing power parity, PPP) - compared to an average of US$4,054 for all developing countries, US$2,149 for low income countries and US$28,741 for high income countries (data from United Nations Development Report, 2004).

The most recently measured doctor-patient ratio in Tanzania was 1 to 25,000 and health expenditure (PPP) US$26 per capita. Each year about 0.5% of the total population of Tanzania die from HIV/AIDS and cancer and few of these patients receive any palliative care. The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification and careful assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Unfortunately, this is simply not available to the vast majority of patients in Tanzania, and most endure a great deal of pain and suffering in the terminal phases (and often also before they become terminal) of their disease. However, the HIV/AIDS epidemic has had a major impact on Tanzania’s policy makers who have now accepted that palliative care is greatly needed in order to improve the quality of life and minimize suffering among patients with incurable conditions – and to help their families cope in these difficult times. Accordingly, a number of palliative care programs have been initiated, both by the government and also by non–governmental (NGO) organizations, in an attempt to provide care and support to people living with HIV infection and other terminal illnesses.

Palliative Care Initiatives in Tanzania

The government, through the Tanzania Commission on AIDS (TACAIDS) and the Ministry of Health, developed a mid-term strategic plan for 2003-2006, which addresses measures relating to care and support for terminally ill patients. The strategy includes both clinic and home-based palliative care initiatives and although stimulated by the AIDS epidemic, also covers cancer, given that many HIV-infected individuals present with, or develop HIV-related cancers, such as Kaposi’s sarcoma and lymphomas.

Palliative Care Centers

So far palliative care has been introduced in the following centers in the country:

Ocean Road Cancer Institute (ORCI) - a government institution situated in Dar es Salaam which provides care for cancer patients, some of them with HIV-related cancers. ORCI has a hospital-based palliative care team whose main activity is to identify and manage the palliative care needs of cancer patients. Over 80% of patients seen in this institute receive cancer treatment (i.e., radiotherapy or chemotherapy) as palliative treatment, since there is no possibility of curing them of their disease. At the ORCI, pain management is based on the WHO pain control ladder, and liquid oral morphine is being used as the step 3 drug.

Muheza Hospice Care - an NGO working within a designated District Hospital in Muheza, in the Tanga Region of northeastern Tanzania. The hospice provides hospital-based palliative care services, a hospital support team, a day care center, home care and education and training. Care is provided for both HIV/AIDS (70%) and cancer patients (30%).

Pastoral Activities and Services for people with AIDS Dar es Salaam Archdiocese (PASADA) - the Catholic Church provides services for patients with HIV/AIDS in the Dar es Salaam region.

SELIAN Lutheran Hospital Hospice - an NGO, American-supported hospital-based palliative care program situated in the Arusha Region (in the northern part of Tanzania) that deals mainly with HIV/AIDS patients.

Winmware Hospice - in Mbeya Region (in the southwestern part of Tanzania), Winmware Hospice is developing a home-care service for patients with AIDS.

Availability and Accessibility of Palliative Care Drugs

The essential drugs required for effective palliative care, i.e., those which are required for pain and symptom control, including gastrointestinal, respiratory, urinary or neurological symptoms, are available through a Central Medical Stores Department. These include drugs for opportunistic infections such as candidiasis and tuberculosis. ORCI was permitted to procure powdered morphine from the Medical Stores Department in November 2001. The powder is processed into liquid oral morphine at the ORCI Pharmacy. All the other centers receive their required oral morphine supplies from ORCI. Bearing in mind that pain is the most common symptom among patients with advanced cancers or opportunistic infections, this arrange.ment will have to be revised because it may decrease, rather that increase, access to oral morphine. Another area which needs to be addressed is the fact that patients generally develop pain and other symptoms whilst in their home community setting, which makes it necessary to distribute oral morphine at the community level. This need, however, will only be met after training of community-level prescribers and modifying existing policy regard.ing the use of opioids in Tanzania.

Training in Palliative Care

Currently, palliative care is not included in the training curriculum for the medical/nursing schools in Tanzania. The Hospice Africa Uganda has a distance learning diploma program in palliative care, and so far, three candidates from Tanzania have joined the program. This is not sufficient to meet the needs of Tanzania, however, and it is the intention of ORCI to put in place mechanisms for disseminating knowledge about palliative care and to advocate for the inclusion of palliative care training in the medical/ nursing school curriculae. The preparation of palliative care training guidelines for health care providers is already in progress.

Palliative Care Policy

At the moment there is no national policy and no national guidelines for palliative care in Tanzania. Following a WHO-supported situation analysis and needs assessment study for palliative care services in Tanzania in 2002/2003, a proposal for the development of a policy for palliative care was developed and endorsed by the Ministry of Health. The proposal recommends that: 1. Palliative care programs should be incorporated into the existing health care system. 2. Health workers are adequately trained in palliative care. 3. Adequate support is provided for palliative care programs, particularly in the home. 4. National health policies should be revised to include palliative care. 5. Hospitals are able to offer appropriate specialist back-up and to support home care. 6. The availability of opioid, non-opioid and adjuvant drugs is assured.

Research on Palliative Care in Tanzania

Very little research in the area of palliative care in Tanzania has been undertaken. In the year 2002, a multicountry situation analysis and needs assessment study coordinated by the World Health Organization was done. The results from this study, are summarized in the website: www. who.int/cancer/media/en/614.pdf.

The interviewees expressed the need for comprehensive palliative care and the majority of patients (82%) mentioned home to be their preferred place for care. Some 82.5% of family caregivers expressed a lack of basic knowledge for caring for their sick ones.

The Way Forward in Palliative Care in Tanzania

A Country Palliative Care Team has been formed. It is the intention of the team to lobby for resources for implementing the proposal for countrywide, home-based, palliative care services. In the meantime, the team is striving to create links with the existing programs that are already providing home-based and clinic-based care for HIV/AIDS patients.

Conclusion

Palliative care in Tanzania is still in its infancy, despite the existing demand in the community. There is great hope that execution of the country proposal, whether partly or wholly, would dramatically change the existing picture. We look forward to receiving support both from within and outside Tanzania to help us meet this much needed service for our patients. We expect that in the very near future, collaboration with INCTR’s Palliative Care Program will be initiated and that this will act as a catalyst to our existing palliative care efforts in Tanzania.

Twalib A. Ngoma
Ocean Road Cancer Institute (ORCI), Dar es Salaam, Tanzania

http://www.inctr.org/publications/2004_v04_n04_s02.shtml