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Hogerzeil H.V.,University of Groningen | Liberman J.,be Center for Law and Cancer | Wirtz V.J.,National Health Research Institute | Kishore S.P.,Harvard University | And 5 more authors.
The Lancet | Year: 2013

Access to medicines and vaccines to prevent and treat non-communicable diseases (NCDs) is unacceptably low worldwide. In the 2011 UN political declaration on the prevention and control of NCDs, heads of government made several commitments related to access to essential medicines, technologies, and vaccines for such diseases. 30 years of experience with policies for essential medicines and 10 years of scaling up of HIV treatment have provided the knowledge needed to address barriers to long-term effective treatment and prevention of NCDs. More medicines can be acquired within existing budgets with efficient selection, procurement, and use of generic medicines. Furthermore, low-income and middle-income countries need to increase mobilisation of domestic resources to cater for the many patients with NCDs who do not have access to treatment. Existing initiatives for HIV treatment offer useful lessons that can enhance access to pharmaceutical management of NCDs and improve adherence to long-term treatment of chronic illness; policy makers should also address unacceptable inequities in access to controlled opioid analgesics. In addition to off-patent medicines, governments can promote access to new and future on-patent medicinal products through coherent and equitable health and trade policies, particularly those for intellectual property. Frequent conflicts of interest need to be identified and managed, and indicators and targets for access to NCD medicines should be used to monitor progress. Only with these approaches can a difference be made to the lives of hundreds of millions of current and future patients with NCDs.


O'Brien M.,Global Access to Pain Relief Initiative | Mwangi-Powell F.,African Palliative Care Association | Adewole I.F.,University of Ibadan | Adewole I.F.,African Organisation for Research and Training in Cancer | And 7 more authors.
The Lancet Oncology | Year: 2013

WHO expects the burden of cancer in sub-Saharan Africa to grow rapidly in coming years and for incidence to exceed 1 million per year by 2030. As a result of late presentation to health facilities and little access to diagnostic technology, roughly 80% of cases are in terminal stages at the time of diagnosis, and a large proportion of patients have moderate to severe pain that needs treatment with opioid analgesics. However, consumption of opioid analgesics in the region is low and data suggest that at least 88% of cancer deaths with moderate to severe pain are untreated. Access to essential drugs for pain relief is limited by legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of health-care providers, procurement difficulties, weak health systems, and concerns about diversion, addiction, and misuse. However, recent initiatives characterised by cooperation between national governments and local and international non-governmental organisations are improving access to pain relief. Efforts underway in Uganda, Kenya, and Nigeria provide examples of challenges faced and innovative approaches adopted and form the basis of a proposed framework to improve access to pain relief for patients with cancer across the region. © 2013 Elsevier Ltd.


Harding R.,King's College London | Selman L.,King's College London | Powell R.A.,African Palliative Care Association | Namisango E.,African Palliative Care Association | And 6 more authors.
The Lancet Oncology | Year: 2013

Roughly half a million people die of cancer in sub-Saharan Africa every year. Despite rapid expansion of palliative care for cancer, coverage remains woefully inadequate. The WHO public health strategy for palliative care aims to increase access to palliative care services through its integration into health-care systems. We present the available evidence for the four WHO strategy pillars of policy, education, drug availability, and implementation, and propose a fifth pillar of research activity to stimulate improvement of care. Increased attention to the generation of research evidence is essential to achieve quality and coverage of appropriate palliative care for patients with advanced cancer in sub-Saharan Africa. The use of locally validated, patient-reported outcome measures is an important advance in the measurement and improvement of care and patient wellbeing. Palliative care for patients with cancer in Africa currently receives far less research attention than does palliative care for patients with HIV/AIDS, but in view of projected increasing cancer incidence in the region, generation of local evidence to inform and allow assessment of palliative care for patients with cancer is urgently needed. © 2013 Elsevier Ltd.


Mwangi-Powell F.N.,African Palliative Care Association | Mwangi-Powell F.N.,Open Society Foundations | Powell R.A.,African Palliative Care Association | Harding R.,King's College London
Current Opinion in Supportive and Palliative Care | Year: 2013

Purpose of review This narrative review examines evidence for models of palliative and end-of-life (eol) care delivery in sub- Saharan Africa (SSA) since 2010. It highlights recent developments, on-going challenges and innovative approaches used to address obstacles to increased access to care. Recent findings Electronic databases were searched for the literature published in English during the period 2010-2012 around broad thematic areas of palliative and eol care delivery models in SSA. Literature showed increased palliative and eol care service development, underpinned by advocacy work undertaken by regional and national palliative care associations. Despite this increase, care provision remains inadequately integrated in national public health agendas and systems. Consequently, it continues to be heavily reliant upon nongovernmental, community-based and home-based care (HBC) models. Efforts are, however, underway to integrate palliative care into national health systems, which should increase access to care. National policies and government financing will be important to sustain this integration. Summary Although community and HBC programs remain primary models of palliative and eol care delivery in SSA, there is an urgent need to develop a public health approach that integrates care into national health systems to increase accessibility. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Namisango E.,African Palliative Care Association | Harding R.,King's College London | Harding R.,University of Cape Town | Atuhaire L.,Makerere University | And 4 more authors.
Journal of Pain | Year: 2012

This study aimed to determine the prevalence, intensity, associated factors, and effect of pain among ambulatory HIV/AIDS patients. Three-hundred two adult ambulatory HIV/AIDS patients were consecutively recruited from HIV/AIDS outpatient clinics at 2 teaching hospitals in Uganda. The presence and intensity of pain were self-reported using the Brief Pain Inventory (BPI); symptom data were collected using the Memorial Symptom Assessment Scale (MSAS-SF); and quality of life (QOL) was assessed using the Medical Outcome Scale-HIV. Forty-seven percent reported pain in the 7 days prior to the survey and pain was a symptom at the time of diagnosis for 68%. On the 0 to 10 numeric scale, 53% reported mild pain (1-4 rating), 20% reported moderate pain (5-6 rating) while 27% reported severe pain (7-10 rating). Gender was not associated with pain intensity, but reduced functional performance, increasing number of symptoms, advanced HIV disease, physical symptom distress (MSAS-SF), and number of health comorbidities were significantly associated with pain intensity (P <.04). Increasing pain intensity was associated with greater functional ability impairment (BPI functional interference index) and poorer QOL. Pain is a common symptom among ambulatory HIV/AIDS patients and has a debilitating effect on QOL. There is a significant unmet need for pain relief in the population. Perspective: This article discusses the characteristics and effect of pain on function and QOL in East African patients. It also contributes information on characteristics of HIV/AIDS adult patients in the East Africa demonstrating the aspects in which pain is similar across different cultures. © 2012 by the American Pain Society. Published by Elsevier Inc. All rights reserved.


Harding R.,King's College London | Powell R.A.,African Palliative Care Association | Kiyange F.,African Palliative Care Association | Downing J.,African Palliative Care Association | Mwangi-Powell F.,African Palliative Care Association
Journal of Pain and Symptom Management | Year: 2010

Context: Although pain and burdensome symptoms among HIV-infected persons can be effectively managed, the availability of opioids and other symptom-controlling drugs is a particular challenge in sub-Saharan Africa. Objectives: This study aimed to identify current drug availability and prescribing practices in 12 sub-Saharan African countries and to examine the barriers and potential facilitators for use of opioids and other key HIV/AIDS symptom-controlling drugs. Methods: This was a cross-sectional survey, integrating data from palliative care facilities and competent authorities within ministries of health in 12 African countries. Results: Of 62 responding facilities, problems were reported in accessing named nonopioids, with a small number of facilities unable to dispense them. Less than half the facilities were currently prescribing opioids of any strength. Further problems were identified in terms of the availability and supply continuity of named antiemetics and anxiolytics. The data identified a number of systemic problems, suggesting that opioid supply issues are similar to less controlled drugs, such as antiemetics. Among competent authorities, there was no agreement on whether further opioid expansion was possible. Integration of data from care facilities and competent authorities highlighted a disparity in the understanding of the availability of specific drugs, with competent authorities naming drugs that were not listed by any responding facility in their respective country. Conclusion: This study shows that opioid expansion needs to balance supply and skills: Currently there are insufficient trained clinical personnel to prescribe, and supply is unreliable. Efforts to expand supply should ensure that they do not weaken current systems. © 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.


Grant
Agency: Cordis | Branch: FP7 | Program: CSA-CA | Phase: HEALTH-2007-2.4.1-5 | Award Amount: 1.83M | Year: 2008

There is little coordination in undertaking research in end of life care. This is due to lack of agreement on what constitutes end of life cancer care, no information on public or clinical priorities for achieving a good death in a culturally diverse Europe, few appropriate measures of quality, and a lack of established best practice. PRISMA aims to deliver an integrated programme to coordinate research priorities and practice. The work packages will undertake actions to identify cultural differences in end of life care, establish a collaborative research agenda informed by public and clinical priorities, and draw together best practice and resources for quality measurement. The Palliative Outcome Scale (POS) is a multidimensional tool that measures the physical, psychological, spiritual and information needs of patients and families at the end of life. It has been culturally adapted in 20 EU countries and widely used by over 100 services to evaluate and improve quality of care. However, there have been no opportunities to share practice, identify shared and country-specific domains, and coordinate to improve research across Europe. By coordinating POS use, PRISMA will offer a model to optimise end of life care research and measurement and identify both commonalities and differences in the evaluation of quality indicators for cancer patients and their families across Europe. Incorporating wide public/clinical consultation with the coordination of POS use into this programme will advance scientifically sound practice while taking account of cultural difference and public expectations. Through integrated action, we will exchange experience, shape best practice, and plan future collaboration through identification of priorities. This will enable research to harmonise and reflect the diversity and the needs of European citizens and clinicians. Support for the POS ensures that direct impact is felt between research and daily clinical practice.


Powell R.A.,African Palliative Care Association
Progress in Palliative Care | Year: 2013

Approximately 10 million people need palliative care for life-limiting illnesses across Africa. Although noncommunicable diseases are significant sources of morbidity and mortality globally, in Sub-Saharan Africa infectious diseases constitute the major disease burden, with HIV/AIDS its primary determinant. Despite this need, and the progress made in advancing service provision, palliative care coverage on the continent remains deficient. Following the World Health Organization's enhanced public health approach, palliative care providers on the continent have used the modality of home-based care. Central to this home-based palliative care are family carers. Against a backdrop of eroding extended kinship and community structures, a result of a combination of modernization and the demographic impact of HIV/ AIDS, the normative, moral, and economic fabric that previously bound together the extended family is disentangling, rendering the assumption that, in African caring systems the capacity of the extended family to withstand crises is inexhaustible, baseless. Given the engendered nature of care provision in Africa, the primary burden of caring for the ill traditionally falls on women, especially the old and young. These family caregivers face multiple challenges, including limited knowledge and caring skills, the costs of caring, stress and burnout, care burden, the challenges and support for caregivers, and HIV-related stigma and discrimination. The article concludes by suggesting a number of ways by which familial care giving and research on the continent can be improved. © W. S. Maney & Son Ltd 2013.


Powell R.A.,African Palliative Care Association | Kaye R.M.,African Palliative Care Association | Ddungu H.,African Palliative Care Association | Mwangi-Powell F.,African Palliative Care Association
Journal of Pain and Symptom Management | Year: 2010

International health and drug regulatory authorities acknowledge that analgesics (especially opioids) are insufficiently available for pain management in many countries. In Africa, reported morphine consumption is far below the global mean, with multiple factors hampering opioid supply. Since 2006, the African Palliative Care Association has hosted three regional drug availability workshops across the continent to address this issue. Using an interactive format, the workshops have identified country-specific barriers to opioid and other essential medication accessibility before supporting participants to develop action plans to address recognized impediments. Despite multiple challenges, a number of successes have arisen from the implementation of the plans. However, key issues remain, including the introduction of supportive policy environments, effective educational initiatives, and measures to address supply-chain obstacles impeding drug availability. © 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc.


Mwangi-Powell F.,African Palliative Care Association
Progress in Palliative Care | Year: 2012

In Africa, the need for palliative care is immense, but largely unmet. The World Health Organization (WHO) estimates that approximately 9.67 million people are in need of palliative care across the continent. © W.S. Maney & Son Ltd 2012.

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