Elsevier

The Lancet

Volume 365, Issue 9475, 4–10 June 2005, Pages 1971-1977
The Lancet

Review
Palliative care in sub-Saharan Africa

https://doi.org/10.1016/S0140-6736(05)66666-4Get rights and content

Summary

Control of pain and symptoms and terminal care are necessary for quality HIV and cancer care in sub-Saharan Africa. However, what constitutes feasible, accessible, and effective palliative care, and how to develop such services, remains to be resolved. Africa-specific palliative care includes components that carry resource implications. Home and community-based care has been largely successful, but community capacity and the resources and clinical supervision necessary to sustain quality care are lacking. Coverage and referrals must be primary concerns. Simple lay and professional protocols have been developed, but opioid availability remains a major constraint. Areas of good practice, and areas where further success may be achieved include: attention to community needs and capacity; explicit frameworks for service development and palliative-care integration throughout the disease course (including antiretroviral provision); further education and protocols; strengthening and dissemination of diverse referral and care systems; increasing advocacy; and funding and technical skills to build audit and quality assessment.

Section snippets

Background

In 2003, there were an estimated 26·6 million people in sub-Saharan Africa living with HIV, 3·2 million new infections, and 2·3 million AIDS-related deaths.1 Additionally, WHO estimates that there were 0·5 million deaths per year from cancer in Africa,2 and that by 2020, 70% of new cancer cases will be in the developing world.3 Cancer rates in Africa are expected to grow by 400% over the next 50 years.4 Palliative care has gained broad support as an important part of disease management,5 and

Results

We identified 26 palliative care service organisations, which were described in 38 reports. Research, monitoring, and evaluation findings from 15 studies were reported by eight organisations. A further 169 relevant publications and reports were included. The full review and extraction tables with reference lists are available to download free of charge.15

Cultural dimensions

A good death in Africa varies culturally and historically;16 for example, bearing bad news could be seen as the cause of a terminal illness, or as incompatible with the clinician's responsibility to cure.17, 18 Traditions dictate appropriate models and places of care: sick people might be removed from villages to avoid risk to the community, or returned from hospital to the community to avoid the dangers of crowded wards and toxic drugs from developed countries.19 Therefore, the development of

Place of care

A lesson from the foundation of hospice at Selian Hospital in Arusha, Tanzania, a small service attached to existing cancer services, has resonance for all countries: “opportunities accompany the problems. Hospice care doesn't have to fit any particular model”.23 All countries need palliative care that meets cultural, spiritual, and economic needs of its people,44 but it may be offered in forms not recognised as a traditional hospice model.

Resource constraints direct the site of care, with 80%

Conclusions

Limitations in identifying factors associated with success, were (1) the shortage of research activity, (2) the paucity of written experience, and (3) the potential bias in reports written mainly for funders. The risk with the last issue is that, understandably, services may present themselves favourably, and challenges and even failures might not be fully shared. We could not make assumptions on any service, and our review relies entirely on the existing published work. We hope that

Search strategy and selection criteria

We used a combination of a systematic review and documentary analysis. We searched biomedical databases with supplementary hand searches in July, 2003. We searched MEDLINE (1966–2003), CINAHL (1982–2003), AMED (1985–2003), CancerLit (1975–2003), PsychInfo (1974–2003), EMBASE (1980–2003), Science Citation Index (1981–2003) and Social Sciences Citation Index (1981–2003). Search terms were the union of “hospice”, “terminal care”, “terminally ill”, “palliat*”, “hospice*”, “dying”, “end of

References (79)

  • S Ramsay

    Raising the profile of palliative care for Africa

    Lancet

    (2001)
  • K Morris

    Cancer? In Africa?

    Lancet Oncol

    (2003)
  • SL Beck

    Health policy, health services, and cancer pain management in the New South Africa

    J Pain Symptom Manage

    (1999)
  • AIDS Epidemic Update

  • C Sepulveda et al.

    Quality care at the end of life in Africa

    BMJ

    (2003)
  • S Browde

    Expanding the definition of palliative medicine and integrating it into the mainstream

    S Afr Med J

    (2001)
  • Progress report: Community health approach to palliative care for HIV/AIDS and cancer patients in Africa

    (2002)
  • BM Minja

    Cancer pain control in Africa (state of the art)

    J Palliat Care

    (1989)
  • A Soyannwo et al.

    Management of cancer pain—a survey of current practice in West Africa

    Niger Postgrad Med J

    (2001)
  • R Drew et al.

    Options for extending the reach of palliative care in Kenya: a summary report for the Diana Princess of Wales Fund

    (2001)
  • C Bateman

    GP's vision kick-starts palliative training

    S Afr Med J

    (2002)
  • Cancer and the Third World

    Lancet

    (1984)
  • PA Singer

    Quality end-of-life care: Patients' perspectives

    JAMA

    (1999)
  • AIDS: palliative care. UNAIDS technical update

  • National cancer control programmes: policies and managerial guidelines

    (2002)
  • R Harding et al.

    Palliative care in Sub-Saharan Africa: an appraisal

    (2004)
  • T Walter

    Historical and cultural variants on the good death

    BMJ

    (2003)
  • K Adamolekun

    Openness of health professionals about death and terminal illness in a Nigerian teaching hospital

    Omega

    (1998)
  • TF Solanke

    Communication with the cancer patient in Nigeria. Information and truth

    Ann N Y Acad Sci

    (1997)
  • M Gelfand

    Traditional African attitudes towards death and dying

    Cent Afr J Med

    (1983)
  • R Harding et al.

    Current HIV/AIDS end-of-life care in sub-Saharan Africa: a survey of models, services, challenges and priorities

    BMC Public Health

    (2003)
  • P Somse

    Evaluation of an AIDS training program for traditional healers in the Central African Republic

    AIDS Educ Prev

    (1998)
  • M MacLachlan

    Sustaining health service developments in the ‘Third World’

    J R Soc Health

    (1993)
  • S Williams

    Zimbabwe

    Palliat Med

    (2000)
  • K Hartwig

    The development of hospice care in Arusha, Tanzania: lessons from the neighbouring states of Kenya and Uganda

    J Palliat Care

    (2001)
  • Tenth Annual Report April 2002–March 2003

    (2003)
  • S Foster

    Supply and use of essential drugs in sub-Saharan Africa: some issues and possible solutions

    Soc Sci Med

    (1991)
  • LGL Soares

    Poor social conditions, criminality and urban violence: unmentioned barriers for effective cancer pain control at the end of life

    J Pain Symptom Manage

    (2003)
  • C Bateman

    Can KwaZulu-Natal hospitals cope with the HIV/AIDS human tide

    S Afr Med J

    (2001)
  • L Swartz et al.

    Managing chronic diseases in less developed countries

    BMJ

    (2002)
  • AD Harries et al.

    High early death rate in tuberculosis patients in Malawi

    Int J Tuberc Lung Dis

    (2001)
  • Grahamstown Hospice “Quality of Life” project

    (2002)
  • E Kikule

    A good death in Uganda: survey of needs for palliative care for terminally ill people in urban areas

    BMJ

    (2003)
  • SA Murray et al.

    Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers

    BMJ

    (2003)
  • J Ngalula et al.

    Health service use and household expenditure during terminal illness due to AIDS in rural Tanzania

    Trop Med Int Health

    (2002)
  • P Kraus et al.

    HIV infection and its implications for palliative care in South Africa

    Prog Palliat Care

    (2002)
  • H Kebirungi

    Priority setting in developing countries. Proceedings of the conference “Priorities in Health Care”, Norway 2002. Hospice Uganda

    J Palliat Care

    (2003)
  • K Defilippi

    Palliative care issues in sub-Saharan Africa

    Int J Palliat Nurs

    (2000)
  • EO Nyambedha et al.

    Changing patterns of orphan care due to the HIV epidemic in western Kenya

    Soc Sci Med

    (2003)
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