1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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: 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
1 Ngoma T. et al. Int J Cancer Jun 15;136(12):
2 McHembe MD et al. World J Surg Oncol Oct 4;11:257.
3 Ferlay J et al. Int J Cancer. Int J Cancer Mar 1;136(5):E
4 Fliss EM et al. Palliative Medicine. 2014, 28(1) 49 –58

8. 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 [unpublished data]

9. 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 – / 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

10. 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

11. 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

12. Palliative Care at KCMC
Cross sectional study at KCMC Medical ward January
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 [unpublished data]

13. 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

14. 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

15. 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

16. Thank you