Palliative Care in Tanzania Dr. med. Oliver Henke DIPH Cancer Care Centre Kilimanjaro Christian Medical Centre Palliative Care in Tanzania FCCT Symposium 29. April 2017 University of Minnesota - Minneapolis

Overview Palliative Care (PC) in Tanzania Development of PC in Tanzania Current need of PC PC at Kilimanjaro Christian Medical Centre

Development of PC in Tanzania Poor access to ARV medication in the 1990´s -> NGO´s and Missions started PC service to AIDS patients 1996 Ocean Road Cancer Institute implemented PC into their service 1999 Selian Hospice in Arusha was established to provide home based services PASADA = pastoral activities and services for people with AIDS 2001 Muheza (Tanga) and PASADA (Dar Es Salaam) established PC services

Development of PC in Tanzania 2006 Tanzania Palliative Care Association (TPCA) was founded to coordinate service providers and stakeholders on national level and to connect with MoH 2006 ELCT established a programme to provide PC in 13 hospitals throughout the country 2017 according to TPCA 65 health facilities provide PC to the severe ill and dying patients in Tanzania

Development of PC in Tanzania Education and Training Development of PC in Tanzania 2008 International Medical and Technological University integrated PC training into the undergraduate curriculum 2015 University of Dodoma integrated PC into the undergraduate curriculum ORCI integrated PC into the postgraduate training in Oncology´s masters programme Selian Hospice offers yearly certificates in PC Different short courses / trainings offered by various organizations

Development of PC in Tanzania Education and Training Development of PC in Tanzania In 2017, no postgraduate Diploma, Bachelor or Masters Programme in Palliative Care available

Need of Palliative Care Oncology perspective: ~ 80% of all Cancer patients are diagnosed in Stage III and IV 1,2 Need of Palliative Care Incident rate: 123.7 cases/100,000 3 -> 62,000 new Cancer patients annually -> 49,500 „advanced stage“ Cancer Patients -> min. 69% who die need PC (HIC) 4 -> 34,000 patients in need of PC Taking into consideration that Stage III patients are widely not curable due to lack of multimodal treatment Last census 2013: 49,25 million 4. Kings college in london = all deaths in england 2006 - 2008 1 Ngoma T. et al. Int J Cancer. 2015 Jun 15;136(12):2875-9. 2 McHembe MD et al. World J Surg Oncol. 2013 Oct 4;11:257. 3 Ferlay J et al. Int J Cancer. Int J Cancer. 2015 Mar 1;136(5):E359-86. 4 Fliss EM et al. Palliative Medicine. 2014, 28(1) 49 –58

Need of Palliative Care Internal Medicine perspective: 59% of all in-patients on Medical Ward at KCMC suffer from life limiting diseases 1 30% Cancer 21% HIV/AIDS 14% advanced heart disease 5% renal failure 4% respiration failure 4% advanced liver diseases Need of Palliative Care Cross sectional study, conducted January 2016 on medical and pediatric ward (Emma Grace Lewis) 1 Lewis EG at al. 2017 [unpublished data]

Need of Palliative Care WHO Global Health Estimates: Need of Palliative Care Tanzania´s need 90,000 – 136,000 Based on a framework = mortality data from diseases known to need palliative care and estimated pain prevalence 178.4 – 272.9 / 100,000 Rates for people in need of palliative care 1 1 Higginson IJ et al. Oxford and New York: The Wessex Institute for Health Research and Development, 1997

Need of Palliative Care The current setting: Lack of opioids in the majority of health care facilities 1 In 2010 only 4 hospitals hold license to dispense morphine 2 Low prescription rate of opioids 1 Lack of trained professionals 3 No financial sustainability 4 Need of Palliative Care Dispense is a problem, because only 5 liters allowed at a time -> economically nonsense Now, more hospitals holds license, but must be renewed annually Low prescription: 1. morphine scarse resource 2. fear of side effects, esp. Addiction Finance: PC programmes run mostly with fundings from overseas: e.g. Machame from IRC, ended funding, because HIV/AIDS funding went down –> lead to break the network of volunteer workers in the villages 1 Cherny NI et al. Ann Oncol (2013) 24 (suppl_11): xi7-xi13. 2 Hartwig K. et al. Afr J Prm Health Care Fam Med. 2014;6(1) 3 Hartwig K at al. Afr J Prim Health Care Fam Med. 2014; 6(1): 549. 4 Global Atlas of Palliative Care. WPCA and WHO 2014

Palliative Care at KCMC KCMC palliative care team: First established in 2007 Multidisciplinary team (nurses, doctors, social workers, pastors, occuptional therapists, physiotherapists and pharmacists) problem: no staff allocation to PC full-time Lack of funding Morphine procurement problematic Basic training provided to ~ 30 staff members Palliative Care at KCMC Morphine procurement: solution, not powder, maximum 5 liters

Palliative Care at KCMC Cross sectional study at KCMC Medical ward January 2016 1 124 patients - 59% with LLI Palliative Care at KCMC patients with at least 1 analgetic drug: 20% patients with 2 analgetic drugs: 6% patients with morphine: 0% Pain even though 5 patients suffered from overwhelming pain (5/5) patients seen by PC trained staff: 0% 1 Lewis EG at al. 2017 [unpublished data]

Palliative Care at KCMC Present situation at KCMC Palliative Care at KCMC With establishment of the Cancer Care Centre PC became again an urgent topic PC team agreed on these priorities: availability of oral morphine availibility of essential drugs training for KCMC and other surrounding hospitals home based care PC ward rounds PC office/counseling room for patients and families

Palliative Care at KCMC Present situation at KCMC Palliative Care at KCMC Oral morphine is available and distributed to District Hospitals in Kilimanjaro Region Frequent home care is delivered on a small scale 21 staff members from KCMC and other hospitals underwent basic Palliative Care training Weekly palliative care ward rounds are in place Weekly combined oncology and PC ward round to ensure early integration of Palliative Care Office and counseling room opened

Vision Kilimanjaro wide coverage with oral morphine and essential drugs Active palliative care network in the region with professionals and volunteers Post- and undergraduate programmes at Kilimanjaro Christian Medical University College all patients in need of PC in Northern Tanzania have access to pain medication and a peaceful death with dignitiy and without pain WHO: human right to have access to morphine

Thank you