VI. International Donors’ Lack of Attention to Palliative Care

International donors are uniquely placed to facilitate the integration of palliative care into Kenya’s HIV/AIDS response. To date, however, they have failed to do so effectively.

Kenya’s most important international health donor is the United States, through the President’s Emergency Plan for AIDS Relief(PEPFAR). In 2009, PEPFAR funding for Kenya was approximately US$534 million, more than the Kenyan government’s total health budget.[287] The legislation that established PEPFAR in 2003 included a non-binding direction that 15 percent of PEPFAR funds should be spent on palliative care.  Although this direction was omitted from the legislation that funded PEPFAR from 2008, PEPFAR has assigned very large sums to activities that it considers palliative care.[288] However, PEPFAR has adopted a very broad definition of palliative care, including routine HIV counseling and testing; prevention and treatment of opportunistic infections; and HIV prevention and behavior-change counseling. This definition is much broader than the WHO definition of palliative care, and as a result, little real progress has been made towards improving access to pain treatment.[289] 

In 2007, 600 facilities in Kenya received PEPFAR funding to provide palliative care. A survey covering 10 percent of those facilities found that commonly provided services included pre- and post-test counseling (90 percent), prevention programs (90 percent), nutrition programs (98 percent) and patient support groups (75 percent). By contrast, none of the facilities stocked oral morphine or any other strong oral opioid for treating chronic severe pain. While 83 percent of the facilities reported dispensing weak non-opioid pain relievers, such as paracetamol, only 27 percent reported dispensing weak opioids, such as codeine.[290] Professionals working for PEPFAR-funded programs confirmed that this situation remained unchanged in 2010. PEPFAR-funded facilities usually stock weak non-opioid pain relievers but no strong opioids, and there is no systematic effort to ensure the availability of oral morphine or alternative medicines for treating severe chronic pain.[291] 

PEPFAR funds the Supply Chain Management System (SCMS), which the Kenyan and United States governments could use to improve the availability of oral morphine and other pain medicines. SCMS is a collaboration of private-sector, faith-based and nongovernmental organizations that “helps strengthen and build reliable, secure and sustainable supply chain systems [and] helps to reduce the price of essential medicines by working closely with clients to plan future procurement, pooling orders to buy in bulk [and] establishing long-term contracts with manufacturers.”[292] Although governments and PEPFAR-funded health facilities can purchase oral morphine from SCMS, very few have done so.[293] This may be a missed opportunity.

PEPFAR staff members include clinicians who are influential in the countries where they work and in international institutions such as WHO. For this reason, increased attention to pain treatment within PEPFAR could help bring about important reforms in Kenya and internationally, such as the inclusion of pain treatment and palliative care in HIV clinical guidelines; the revision of medical and nursing school curricula to include pain treatment and palliative care; the inclusion of pain assessment in initial patient assessment forms, and the addition of access to pain treatment as a factor in the routine monitoring and evaluation of HIV programs.

Other key international health donors in Kenya include the Global Fund to Fight AIDS, Tuberculosis and Malaria; the governments of the United Kingdom, Japan, and Germany; and multilateral agencies such as UNICEF, UNAIDS, the World Bank, and the European Union.[294]  There are also two important private US donors, the Clinton Health Access Initiative—which has a focus on pediatric HIV treatment—and the Bill and Melinda Gates Foundation.[295] 

Unfortunately, international funding for HIV/AIDS programs dwarfs funding for strengthening the health system as a whole, as well as for child health care, cancer treatment, and palliative care. Nonetheless, international donors have also made some important contributions to these areas. The US government has helped to fund a new children’s ward at Kisumu’s provincial hospital and is supporting some research and treatment on childhood cancer. Some international NGOs support Kenyan hospices, including Hospice Care Kenya, the Diana Princess of Wales Memorial Fund Palliative Care Initiative, and Hospice Care Inc.

Many international donors and NGOs serve orphans and vulnerable children (OVCs), and specifically children affected by HIV. However, their programs usually do not explicitly include palliative care.