2019; Volume 20, No 6, June
Around the World: Progress report
At just 0.38 mg per person annually, Uganda is among the lowest consumers of medically prescribed morphine. But need was apparent; in 2016, the PCAU – which is marking its 20th anniversary this year — set out to change things.
Well-Planned, Sustained Advocacy Pays Off in Uganda
Since 2016, a concerted, sustained effort by the Palliative Care Association of Uganda (PCAU) to make prescription pain medicine more readily available in hospitals has had an enormous impact.
Mark Mwesiga
‘When doing the baseline at commencement of American Cancer Society’s Pain Free Hospital Initiative (PFHI), at one hospital we walked through wards and saw children crying in pain,’ says PCAU Programs Manager Mark Mwesiga. ‘We recently went back and the children were smiling. Even a nonmedical person realizes the great change.’
Advocacy paired with
Pain-Free Initiative
The association developed a detailed advocacy plan at the same time as starting the initiative. The challenges at the beginning were great; even though the government pays for all morphine nationally, a key difficulty was an unreliable supply chain.
Gaps were numerous.
Palliative care nurse Martha Rabwoni, right, at Mobile Hospice Mbarara during a community outreach in Mbarara District.
‘Sometimes health facilities do not order properly or they do not use the right ordering forms,’ says Mwesiga. ‘Other times, the National Medical Stores (which supply medical morphine) does not respect reorder levels, or they deliver a wrong order, or they deliver more or less than needed. There could be an occasional stock out at the hospital, or the trained nurse or clinical prescriber has been transferred. Smaller health facilities may not have a full-time, qualified doctor.’
Complicating matters, no one has a handle on actual need, as there is no historical precedent to guide them. ‘If all facilities were supplying the right information on cunsumption,’ Mwesiga knew, ‘we could streamline and supply the demand.’
The effective tactics
PCAU targeted teaching hospitals and Regional Referral Hospitals, and has been doing the following:
- Delegated an officer to follow complaints and hold meetings in each district where persistent stock outs are reported.
- Enacted the PFHI in regional hospitals (13 have been done; 5 remain), a yearlong process for each. ‘There has been remarkable improvement in the knowledge and attitude among health workers about pain management. Even when the project is long gone, the hospitals have introduced continuous medical education for pain medications... A laptop and projector are very important tools for continuous medical education,’ and the Initiative has enabled PCAU to provide them.
Rose Mubiru, right, describes use of morphine medication to cancer patient Janet Nabadda.
- Scheduled rotating meetings once every two months to educate hospital staff on calculating need and ordering practices. In Pain-Free Initiative hospitals ‘a lot has improved; morphine is now consistently manufactured according to the orders.’
- Recently, it convinced the Ministry of Health to develop an ongoing palliative care registry to track how many patients use morphine at each health facility. ‘Once this is known, they can generate information about actual demand.’
PCAU efforts in the education realm have also paid off, with Uganda introducing an Advanced Diploma in Palliative Care Nursing in government training institutions. ‘About 20 nurses have enrolled in the nine-month course at Mulago School of Nursing and Midwifery. We hope the commitments from Uganda Nurses and Midwives Council that graduates will be registered palliative care nurses will materialize.’
A dream, and desire
PCAU has recently expanded its efforts with a pilot PFHI project in two of the country’s biggest not-for-profit hospitals. ‘Our dream and desire,’ says Mwesiga, ‘is that, seeing the benefit of what the initiative can do, the government is convinced that it is in the interest of the country to implement the program in all general hospitals.’
Funding is a constraint, as Uganda does not even have the budget to cover essential services, he says. Regardless, the advocacy work will continue.