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Sunday, 10th December 2017
Palliative care in Africa: the need

The need for palliative care in Africa can seem overwhelming – but at APCA we focus on the enormous opportunities that exist for us and all our stakeholders to make a positive difference to the lives of people with life-limiting illnesses and their families.

Disease burden

According to the Joint United Nations Programme on HIV/AIDS, by 2015, over 36.7 million people globally were living with HIV/AIDS1; 1.8 million are children age 0–14 and of these; only 49% were on treatment. Africa shoulders 70% of the global burden of both paediatric and adult HIV disease. In addition, the incidence and mortality of non-communicable diseases are steadily increasing in the in sub-Saharan Africa; with the four most prevalent globally being cardiovascular diseases, cancers, chronic respiratory disease diabetes.2 They are the principal cause of mortality globally, accounting for 36 million deaths in 2008 (63% of total fatalities),3 with the majority (four-fifths) occurring in LMICs. By 2030 it is projected that deaths due to NCDs will be the most common causes of mortality in developing countries4, attributable to a combination of increasing and ageing populations, the adoption of risk-factor lifestyles, and deficient diagnostic, preventative and curative treatment services.  It is anticipated that by 2020 the largest increases in NCD fatalities will occur in Africa.4These diseases can share major risk factors: tobacco use, unhealthy diet, physical inactivity and harmful alcohol use. Diabetes cases in sub-Saharan Africa are expected to increase from 4.8% prevalence (19.8 million) in 2013, to 5.3% (41.5 million) in 2035, comprised overwhelmingly of the type 2 variant.5 Cancer is also a significant public health problem in the region.6  In 2012 there were 645,000 new cases and 456,000 cancer-related deaths in Africa, and these are projected to nearly double (1.28m new cases and 970,000 deaths) by 2030.7 8 Specific cancer-related problems in African countries include the high percentage related to infection (36%, twice the global average),8 late presentation to clinical services – critical to determining survival rates – and limited access to treatment, including two essential analgesics, surrounded as they are by legal and regulatory restrictions, inadequate training of healthcare providers, procurement difficulties and weak health systems.9 10

Although conditions like diabetes are treatable, palliative care remains important in resource-limited settings where equitable and regular access to appropriate essential medication for chronic conditions remains problematic and effective symptom control commonly remains a clinical challenge. 11 12 Important to note is the fact indeed many other disease conditions, which are highly prevalent in Africa can benefit from palliative care. Examples include sickle cell, heart disease, chronic neurological conditions and end-stage renal failure. 

Unmet demand
For the overwhelming majority of Africans who currently endure these and other progressive, life-limiting illnesses, access to culturally appropriate holistic palliative care (including effective pain management) is simply not available.  A survey of hospice and palliative care services on the continent found that 45 percent of African countries had no identified hospice or palliative care activity, and only nine percent could be classified as having services approaching some measure of integration with mainstream health provision.

Despite Africa's existing disease burden, in 2008 the vast majority of morphine was consumed in industrialised countries. The regional mean in Africa was only 0.33mg compared with the global mean of 5.98mg.  Moreover, to date, only eleven African countries have palliative care plans, programs/policies (Botswana, Ethiopia, Guinea, Libya, Malawi, Mozambique, Zimbabwe, South Africa, Swaziland, Rwanda, Tanzania and Uganda), while Zambia has developed draft policies that are subject to approval by their health ministries.  Only five countries across Africa have palliative care integrated into the curriculum of health professionals, of which only two (Uganda and South Africa) have recognised palliative care as an examinable subject.

Following the WHO estimation of the need for palliative care as one percent of a country's total population, approximately 9.67 million people need palliative care in Africa.  The continent still faces an extreme shortage of healthcare professionals. Tanzania has two doctors and 37 nurses per 100,000 people; Mozambique, three doctors, 21 nurses; Cote D'Ivoire, 12 doctors, 60 nurses. Even South Africa has only one specialist nurse per 39,400 cancer patients. 

Opportunities for change

This vast unmet need for palliative care can only be addressed by the public health approach to palliative care delivery advocated by the WHO and supported by APCA. This ensures the right policy frameworks, resourcing and educational structures are in place for palliative care to reach every man, woman and child in need.

APCA focuses on the enormous opportunities that exist for us and our stakeholders to make a positive difference to people's lives.

References

1      UNAIDS. Global Statistics 2015. Geneva: UNAIDS, 2016

2      World Health Organization.  Non-communicable diseases.  Fact sheet, March 2013.  Source: www.who.int/mediacentre/factsheets/fs355/en/ (accessed 17 November, 2017).

3      Alwan A, Maclean DR, Riley LM et al.  Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries.  Lancet 2010; 376: 1861-1868

4      Wagner K-H, Brath H.  A global view on the development of non-communicable diseases.  Prev Med 2012; 54 (Supp.): S38-S41.

5      International Diabetes Federation.  IDF Diabetes Atlas: Africa at a glance.  Source: www.idf.org/sites/default/files/DA6_Regional_factsheets_0.pdf (accessed 17 November 2017).

6      Jemal A, Bray F, Forman D et al.  Cancer burden in Africa and opportunities for prevention.  Cancer 2012; 118: 4372-4384.

7      International Agency for Research on Cancer.  GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012.  Source: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx (accessed 27 October, 2017).

8      Parkin DM.  The global health burden of infection-associated cancers in the year 2002.  Int J Cancer 2006; 118: 3030-3044.

9      O’Brien M, Mwangi-Powell F, Adewole IF et al.  Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa.  Lancet Oncol 2013; 14: e176-182.

10    Cleary J, Powell RA, Munene G et al.  Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI).  Ann Oncol 2013; Suppl 11: xi14-23

11    Mendis S, Fukino K, Cameron A, Laing R, Filipe Jr. A, Khatib O, et al. The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries. Bull World Health Organ2007; 85: 279-287