Uganda's palliative care model for Africa

In Uganda a palliative care service has been successfully implemented in three districts with outreach to other parts of the country. The key to its success is that service is centered on the patient and focused on the quality of care rather than quantity.

Home is home is where I want to be... Martha (left), a palliative care nurse from Hospice Africa Uganda in the west of the country, cares for her patient at home. The carer (daughter, right) holds written instructions for the medications. Caring for patients in their home reduces anxiety and enhances the emotional wellbeing of the patient and their family.
Photo by Karen Frame

Hospice Africa Uganda's (HAU) palliative care service started in Kampala in 1993 with funds for a team of three over three months. The Government also allowed the importation of low cost powdered oral morphine. The powder continues to be imported, made into liquid form locally and distributed to all mission hospitals and Government services on request.

Mobile Hospice Mbarara and Little Hospice Hoima started to train undergraduate doctors and nurses in palliative care in 1998 with few resources. Today, service, education and training are now carried out from three sites, offering an excellent model for other countries to adapt to their own needs.

National government support

After five years of advocacy led by HAU the Ugandan Government is now committed to palliative care. It was introduced in 2000 as an essential part of the National Health Strategic Plan. Government commitment was further demonstrated in 2004 by the expansion of the law allowing midwives to prescribe pethidine while registered nurses and clinical officers with nine months special training in palliative care can prescribe morphine.

Quality versus quantity

Building a dedicated palliative care team can be time consuming. Focusing on quality rather than quantity of staff works best with limited resources. Team members are chosen for their dedication to the relief of suffering. Relief of pain and symptoms is vital; counselling is difficult when a patient is in pain and their family is upset.

Controlled expansion

Rapid expansion can lead to a decline in the quality of care. AIDS organisations and donors measure success by the number of patients seen. Yet each patient needs time, attention and commitment. When attaching palliative care onto support organisations, palliative care should remain a separate service to ensure that quality of care is maintained.

Planning and reporting

Clear objectives from the outset are essential. Planning should be led by service providers rather than donors who may not be clear about local priorities or who may push for broader inappropriate care. Regular assessment and reporting on service delivery should be shared with donors to ensure better targeting of funds.

Local need

Training must meet local needs. Although outside educators can provide broad training, the practicalities need adapting to local circumstances. Hundreds of medications are available for the control of pain and symptoms in developed countries whereas only 21 are affordable and available to use in Africa. Yet with dedication and these medications, 95 percent of pain can be controlled 95 percent of the time.

Experience from Uganda suggests that governments should:

• be committed to working with the International Narcotics Control Board to make oral morphine, the main affordable analgesic in Africa, available
• extend the prescribing powers of health care providers, as has happened in Uganda, to ensure that drugs are dispensed effectively
• focus on high quality palliative care services that meet local needs.

Anne Merriman
Hospice Africa (Uganda), PO Box 7757, Kampala, Uganda
anne@hospiceafrica.or.ug
www.hospiceafrica.or.ug

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