Advocating a public health approach

National programmes for palliative care offer the most effective means of improving the quality of life for the greatest number of patients and families, even where resources are severely constrained. Palliative care, however, is low on the list of under-resourced governments' health care priorities. What part can advocacy play in raising its profile and promoting its value?

According to the World Health Organization, a public health approach to palliative care has three foundations:

• Governmental policy: adoption of a national palliative care strategy.
• Education: training of health care professionals and creating awareness among the general public.
• Drug availability: assuring the availability of drugs for pain control and symptom management.

These measures, combined with committed leadership to achieve an effective national programme, are vital components for the sustainable delivery of palliative care. However, while these measures are critical, in many parts of Africa they are simply not in place. Consequently, advocacy has a crucial role to play in ensuring these measures are adopted and implemented.

While there are many competing priorities for inadequate resources in Africa, a public health approach to palliative care is feasible. The African Palliative Care Association, which was established to support affordable and culturally appropriate palliative care across the continent, views sustained advocacy as a critical means by which this goal can be achieved by securing the political and financial commitment of government.

The Uganda success story

Whilst successful examples of how advocacy has been used to achieve a public health approach in palliative care are limited, they do exist. One notable example is provided by Hospice Africa, Uganda (HAU), for many years the main advocate for palliative care in Africa. Through targeted advocacy, HAU persuaded the Ugandan Government to include palliative care as an essential part of its National Health Sector Strategic Plan 2000 to 2005.

Palliative care is part of Uganda's minimum health care package, with explicit goals and guidelines for implementation and verification. Moreover, Uganda has an essential drugs programme, and the revision of restrictive drug laws now allows trained palliative care nurses to prescribe and administer oral morphine at home.

Two factors were central to this success: first, effective networking with, and persuasive lobbying of, key government officials and influential supporters. HAU provided specific information and advice on what policies needed to be introduced or revised, as well as assisting with the drafting of policies. Government concerns about the cost effectiveness of these policies were relieved using existing examples of effective and affordable service provision by HAU. Second, HAU conducted formal and informal educational sessions with senior Ugandan doctors to address the common myths of morphine use, such as addiction and intolerance.

Drawn from the Ugandan experience, recommendations for advocacy include the need to:

• target advocacy work at key governmental officials, ideally those who can act as product champions
• ensure the advocacy agenda is specific and explicit
• address any cost effectiveness implications
• use existing practical examples to illustrate and strengthen the case
• address the concerns of other key stakeholders (such as senior doctors) who can impede the implementation of policy changes.

Faith Mwangi-Powell
African Palliative Care Association, P.O. Box 72518, Kampala, Uganda
mpowell@apca.co.ug
www.apca.co.ug

See also

Summary Booklet of Best Practices, UNAIDS Issue 2, UNAIDS: Geneva, 2000

Advocacy Manual, The Diana, Princess of Wales Memorial Fund: London, by Faith Mwangi-Powell, 2002

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