It is disheartening to hear “there is nothing else we can do” after many sessions of chemotherapy or any other treatment for a life-threatening illness at a hospital.
As a patient, you take the long journey home to deal with the physical, spiritual, psychological and financial distress associated with the end-of life when suffering an un-curable disease. As a care-giver, life becomes a pain-filled roller coaster as you watch people you love and care for suffer un-ending pain.
Sadly, this is the story that repeats itself over and over again and particularly in Africa. Many Africans cannot access quality health services due to the high cost of living in the region. Only a dismal number of Africans have quality health insurance funds. Many people in the region pay for health care out-of-pocket. This can prove challenging especially when dealing with terminal illness.
In Uganda however, motivated by the absence of any palliative care services, Dr Anne Merriman founded Hospice Africa Uganda, a model that has been working for Ugandans for over 20 years now.
Hospice Africa Uganda (HAU) is a model facility achieving high clinical care using multifaceted approaches that have addressed policy, legislative and logistical barriers.
The 2015 Quality of Death Index report by the Economist ranks Uganda’s palliative care in Africa second only after South Africa. South Africa has a better economy supporting more palliative care centers, but Uganda’s model provides enhanced services to local patients and their families.
Adoption and use of affordable pain-relievers
At the end of her contract with the National University, Dr Merriman, a British palliative care specialist was invited to Kenya by Nairobi Hospice as their first Medical Director. While in Singapore, Dr Merriman together with local pharmacists had established a formula for oral morphine which was simple to make and affordable for Africa.
This solution made locally in Uganda by combining food coloring, water, a preservative and a pound of morphine powder, has put Uganda in the global ranking as the best quality of death among low-income countries according to the report published by the Economist Intelligence Unit.
A bottle of the green, pink and blue dyed morphine costs about $2. This solution has changed the way people die in Uganda combined with a set of other care services like integrating the psychological, cultural and spiritual aspects of patient care among others.
Governments should prioritize palliative care and services
Availing morphine and other affordable pain-relievers at convenient locations across the nation will play a great role to further help patients in rural areas.
Hospices and other services are mainly located in major urban centers which is not only expensive but also in-accessible due to the long queues of patients waiting to be treated.
For a decade, the Ugandan government following World Health Organization guidelines, has prioritized palliative care under Essential Clinical Services in the National Health Plan (2001–2005). Through this, oral morphine is now freely available to districts that have palliative care nurses or clinical officers. Moreover, it has promoted morphine use down to the rural villages.
To avoid abuse, the founder of HAU says: "You've got to be careful, everything has to be signed for and we have to follow the regulations."
Introduce specialist training and legislative measures to increase access
It is necessary to partner with learning institutions to provide the much needed services to patients. Through institutions of higher learning, training and research can further boost the way in which this care is given in the African countries.
Since 1994, Makerere University has been offering training in palliative care which has propelled the management of those with terminal illness. Additionally, last year, Makerere University commenced its first unit of palliative care under Internal Medicine.
If and when more nurses and doctors in Africa are trained, and the governments endorse the use of morphine and other opioids as mollifying solutions to pain, more patients will spend their last days on earth with relief.
So far, Uganda is the first and only African country that has adopted palliative care for people with terminal illness caused by HIV and cancer, part of its national health plan. Since 2002, morphine has been provided freely by government.
Adopting positive perception about pain-relievers
It was not until 1990 that Sub-Saharan Africa had some form of controlling severe pain among patients. At the time only Zimbabwe and South Africa had introduced means to “good death”.
Although, over the years, many more African nations have adopted the use of palliative care to improve quality of death, much more efforts have to be employed to ensure that those who need the care can afford the services and treatment.
In the beginning, rolling out the use of morphine proved difficult as it was viewed as a drug that could lead to addiction. As such, governments and government agents fought the idea of using morphine to relieve pain and suffering of the terminally ill.
Uganda might not have met all the needs of its citizens especially those living far away from Kampala where the hospice is located. But in all respects, it provides the best model that can be adopted by other countries to provide quality of death.
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