CPC Medications and Materials

There have been significant improvements in the availability and accessibility of essential palliative care medications, including morphine, in the past years across the three countries. The 2010 report by

Human Rights Watch, Needless Pain²⁸, established that there was a lack of morphine in the government hospitals. This has since improved with the purchase of morphine to meet the national estimated need.

Although there are occasional stock-outs of some medications, such as morphine, in South Africa, these usually do not go beyond two weeks and are not regular. Access to pain and symptom medications depends on whether the health workers prescribe the medications for the patients in need. Palliative care practitioners and paediatricians in the public facilities in Zimbabwe noted that there are still some periodic challenges in the availability of morphine. The palliative care situational analysis conducted in 2012²⁹ also reported that morphine was available in most facilities for use in cases of severe pain, although some occasional stock-outs were experienced. It seemed from the discussions that the situation on morphine availability is to a large extent similar to the general trends in the availability of other essential medications.

The main challenge that was highlighted regarding medications for CPC was that health professionals were generally hesitant to prescribe morphine, particularly to children, due to the various myths surrounding its use. Despite the occasional stock-outs and “dry” periods, this reluctance to prescribe and/or administer morphine was noted as a major barrier to effective pain management. The lack of adequate knowledge amongst health professionals and their related fears and negative attitudes were commonly mentioned by respondents in the three countries. Respondents provided a common opinion that there is a need to provide relevant education to both professionals and the public. The NGO hospices and palliative care organisations reported working with public health facilities to ensure access to medications for their patients.

“It is very low and I think health workers need to be capacitated. Generally health workers are “scared”

of morphine and we ask them to give a child morphine they do not want to. So I think the use is quite low and there was a time the hospital was not ordering it so we motivated and advocated and they brought it. They actually complained at some time that it was not being used but it is different for surgeons and anaesthetics so the use is very low.” Paediatrician, Zimbabwe

“Firstly, the pharmacists say it is not being prescribed and there is no need, of course there are other competing priorities so again the availability for me is more connected to lack of awareness in those areas. I remember in one hospital ward the morphine had expired and the reason was because it was not being prescribed so you find in the end the pharmacists in those hospitals will not procure it because it is not being prescribed.” PC Doctor.

There was continued reference to the lack of knowledge, fears and lack of appreciation of the need to prescribe morphine amongst health professionals as is illustrated in the diagrams depicting common terms used in describing the gap in intention to use morphine amongst professionals.

28 Needless Pain, Human Rights Watch, 2010

29 Zimbabwe National Palliative Care Situational Analysis Report, MoHCC, 2012

Figure 19: Key Terms Describing Reasons for Low Uptake of Morphine Use

The fears are compounded by the policy regulations on morphine prescribing. The National Medicine’s Policy in Zimbabwe requires that opioids be prescribed by medical doctors whilst nurses can only prescribe mild analgesics in special circumstances. Morphine consumption in Zimbabwe has largely remained low as indicated by the chart below. The 2009 and 2010 estimates of 1kg annually translate to a very low morphine per capita rate. It was observed that doctors and nurses in Kenya have a very good course on pharmacology so its lack of use is more to do with their perception of the risks, and attitudes in practice. Efforts to address the lack of knowledge, myths and attitudes are mainly in the form of training and awareness. Nairobi Hospice in conjunction with KEHPCA as well as HOSPAZ and Island Hospice in Zimbabwe are running various training workshops. The Kenyan edition of ehospice had plans to address the resistance by some professionals to prescribing morphine.

“Where we did the training we noticed there was a rise in the appropriate consumption of morphine and it was low in those that were not trained.” PC Paediatrician

“…also I think it is not just about availability but training. I think some of the health care workers do not feel comfortable or are not trained to provide these medications to paediatric populations and they have not received the kind of training we would want them to have and so there are cases I have seen where the drugs are available but are not used, practitioners do not feel confident in providing them.” Key Informant, HIV and AIDS Organisation, SA

The national umbrella bodies, KEHPCA, HPCA and HOSPAZ were seen to be pivotal and active in ensuring essential palliative care medications are recognised within the system and are made available.

The medications are included in the national clinical guidelines and essential medications list - Essential Drug List of Zimbabwe (EDLIZ), Kenyan Essential Medicines List (KEML) and the Essential Drug List of South Africa. Policy makers generally felt that the presence of medications such as morphine in clinical guidelines should also be leveraged in changing the perceptions of health workers on its use. In addition, a number of health professionals also emphasised that it will be equally important to educate the community so that there is informed demand creation.

Figure 20: Morphine Consumption in Zimbabwe

Data Source: UN: International Narcotics Control Board (INCB), 2011

Figure 21: Access to Analgesics and Paediatric Formulations and Usage in South Africa

The graph below shows that morphine consumption in South Africa has generally increased in the past years.

Figure 22: Morphine Consumption - South Africa

Data Source: UN International Narcotics Control Board (INCB), 2011

0

Yr-2007 Yr-2008 Yr-2009 Yr-2010 Yr-2011

Kgs

Yr-2005 Yr-2006 Yr-2007 Yr-2008 Yr-2009 Yr-2010

Kgs

Trends in Morphine Consumption - Zimbabwe

No  Data No  Data

Figure 23: Morphine Consumption - Kenya

Data Source: UN: International Narcotics Control Board (INCB), 2011