III. Sub-Saharan Africa
"Before I came [to Kenyatta National Hospital], I couldn't eat or breathe well [because of the pain]. Now that I have been given medicine [morphine], I can eat and breathe. I couldn't sit down, but now I can. I had pain for more than a month. I told the doctor and nurses [at another hospital] that I had pain. It took too long to get pain treatment… Here I got it immediately and started feeling well again."
– Christine L., an 18 year-old woman with Breast Cancer, Nairobi, Kenya.
"We have no pethidine, no DF-118 (dihydrocodeine) and no morphine.... We have children here with advanced HIV; some are in severe pain. The pain management for children with advanced HIV is not enough."
– Nurse, Bondo District Hospital, Kenya.
Sub-Saharan Africa has the lowest consumption of opioid analgesics worldwide. As shown in Table 2, 37 sub-Saharan African countries consume so few opioid medications that even if they were used exclusively to treat pain in patients with terminal cancer and HIV, fewer than 10 percent of those patients could receive adequate pain treatment. Eighteen countries could not treat even one percent of this group of patients, and eight countries reported no consumption of opioids at all during 2006 to 2008.
Healthcare workers who must treat patients in facilities with no pain medications understandably express frustration. When Human Rights Watch visited a Kenyan hospital that had no opioid pain medicines a nurse showed us a child who had suffered severe burns, and said: “If we had diclofenac [a weak non-opioid pain reliever] we would give it, but we don’t have it here.”
Consequently, at least 1.2 million people in sub-Saharan Africa die from cancer or HIV/AIDS without adequate pain treatment each year. This is a very conservative estimate, which assumes that all opioids are used to treat this patient group. It should be considered merely an indicator of the enormous unmet need for pain treatment. In reality, the limited opioids that are available are used to treat patients suffering pain from other causes too. So the real number of terminal cancer and HIV/AIDS patients with untreated pain must be higher, and many other patients with non-terminal cancer and HIV/AIDS and with other diseases are also suffering untreated pain.
While the challenging economic environment and poor health care infrastructure undoubtedly are a major reason for this situation, our survey findings suggest that government failure to take reasonable, low-cost steps to improve availability of opioid analgesics is a significant contributing factor in many countries.
The African countries we surveyed have inadequate government policies to promote palliative care, inadequate medical education in pain treatment and palliative care, and very poor availability of morphine across different healthcare settings, indicating poor supply and distribution systems for opioids. African countries surveyed imposed few of the regulatory restrictions covered in this survey, but in all but one of the countries surveyed respondents reported that physicians’ fears about possible legal sanctions are a barrier to prescribing opioids.
The survey findings highlight that even poor countries can make significant progress in delivering palliative care. Concerted efforts by Uganda’s government and civil society to improve access to palliative care have resulted in the removal of many of the barriers discussed in this survey. During 2006 to 2008 Uganda could already treat a significantly higher portion of its terminal HIV/AIDS and cancer patients than neighboring Kenya (Uganda: 7.4 percent; Kenya: 4.6 percent), even though Kenya’s GDP is significantly higher than Uganda’s. The ongoing process of improving access to palliative care in Uganda, discussed below, means that Uganda’s consumption of opioids has likely increased subsequent to 2008, so that more patients care receive treatment.
As Table 3 shows, there is little government support for palliative care in the seven African countries we surveyed, with Uganda the only country that has a national palliative care policy. Only two of the countries have cancer control policies that reference palliative care; four do not have such policies at all. Four countries surveyed had HIV policies that referred to palliative care but, despite high HIV/AIDS mortality levels, the HIV policies in three countries did not. More positively, most countries have included oral morphine in their essential medicines list although, as discussed below, it’s availability in practice is often very limited.
Survey respondents from Ethiopia and Kenya reported that those countries are currently developing cancer control strategies. Kenya’s strategy is expected to include palliative care.
The availability of education in pain management varied greatly in the African countries surveyed. As Table 4 shows, in three of the seven countries surveyed — Cameroon, Ethiopia, and Tanzania — no instruction in pain management is available at all for physicians. On the other hand, in Uganda, palliative care instruction is compulsory in all undergraduate medical programs and available in postgraduate medical education.
Doctors from several of the African countries surveyed mentioned that some healthcare workers had received post-graduate education in palliative care from foreign institutions in other African countries and Europe through distance learning or programs run jointly between African and non-African institutions. This was the case in countries that had some domestic opportunities for post-graduate training, as well as those that did not. While these programs make an important contribution to building African expertise in palliative care, domestic programs are essential to adequately train sufficient numbers of healthcare workers in pain treatment and palliative care.
Supply and Distribution
Weak supply and distribution systems are a key reason for the low consumption of morphine in Africa. As Table 5 shows, respondents in all seven countries surveyed said that injectable morphine was not available in all hospitals, although it is available in most hospitals in Uganda and South Africa. While oral morphine is available at all tertiary hospitals in Kenya, South Africa, and Uganda, it is only available in some tertiary hospitals in Ethiopia, Nigeria, and Tanzania. In Africa, most health care is provided in a primary healthcare setting such as a health care center or clinics. In four countries surveyed, no health centers have oral morphine. In two countries, even hospices do not have oral morphine. Overall, availability of morphine was best in South Africa and Uganda and worst in Ethiopia and Cameroon. 
While all countries surveyed have some availability of oral morphine, many other African countries do not. According to Anne Merriman, founder of Hospice Africa Uganda, several dozen countries in sub-Saharan Africa, including all 31 Francophone countries except Cameroon, do not have this essential medicine.
Our survey found relatively few restrictive drug regulations in African countries surveyed. None of the countries surveyed impose arbitrary dose limits on prescriptions or restrict prescribing rights to certain types of physicians. None of the countries require a special license for physicians to be allowed to prescribe opioid medications; although Ethiopian drug legislation in a UNODC database states a special license is required, survey respondents said the provision is not enforced in practice.  Only two of the seven countries, Ethiopia and Cameroon, require a special prescription form. Cameroon and South Africa cap the number of days a prescription for opioid medications can cover at 30 days; other countries surveyed did not impose any limit. Key informants from Tanzania reported that while the country’s regulations do not require a special prescription form or impose a limit on the time that prescriptions can cover, some individual medical institutions do impose these.
While our survey found few regulatory barriers, key informants from all African countries surveyed except for Cameroon reported that healthcare workers fear legal sanctions for prescribing opioid medications and identified this fear as a barrier to prescribing them.
Although Uganda is leading the world by developing a program to train nurses to prescribe opioids, most of the African countries surveyed still do not allow nurse-prescribing. Because of low numbers of doctors and large populations living great distances from the nearest doctor or unable to afford the transport to travel to a doctor that is relatively close, allowing trained nurses to prescribe morphine is essential for increasing access to opioids in Africa. At present, only Uganda allows specially trained nurses and clinical officers to prescribe morphine. South Africa is considering changing its regulations to allow nurses to prescribe. Human Rights Watch researchers have previously learned that nurses in some African countries give patients opioids when no doctor is available to do so, although this is contrary to the law.
Table 6: Restrictive Regulation of Morphine Prescribing in Sub-Saharan Africa
Most of the African countries surveyed use oral liquid mixed from morphine powder, which can be prepared for just a few cents per dose. Nonetheless, for many Africans who subsist on less than US$1 per day, the cost remains prohibitive. Healthcare workers reported that many hospices and hospitals subsidize the cost of morphine for all their patients or for their poorest patients. The Ugandan government’s comprehensive effort to improve access to palliative care has included providing morphine free-of-charge.
Doctors in Tanzania reported that weak supply chains make the real cost of providing morphine a burden upon health care services, because staff must travel long distances to collect oral morphine solution, incurring travel expenses and lost staff time. When they are available, other morphine formulations are often significantly more expensive than the lowest price at which they can be purchased internationally, probably due to low demand and weak supply chains.
Best Practice and Reform Efforts: Uganda
In the last 10 years, Uganda has led the African continent in efforts to improve access to palliative care, making significant progress on a number of fronts. The Ugandan government has worked with WHO and religious and nongovernmental organizations to systematically address barriers to access to palliative care.
In its five-year Strategic Health Plan for 2000-2005, Uganda became the first African country to state that palliative care was an essential clinical service for all citizens. Since then, the government has worked to improve the availability of narcotic medications. It added liquid morphine to its essential drug list and adopted a new set of Guidelines for Handling of Class A Drugs for health care practitioners, also a first in Africa. T he Ministry of Health also started importing oral morphine powder and providing oral morphine solution to public health facilities at no cost. Since 2000 opioid consumption in morphine equivalence has increased four-fold from less than 0.2 mg per person to almost 0.8 mg per person in 2008. 
The government’s efforts have not been limited to improved drug provision. In 2004 Ugandan law was amended to allow nurses and clinical officers, once they have completed a nine-month palliative care course, to prescribe morphine.  More than 80 nurses and clinical officers have since graduated from Hospice Africa Uganda’s Clinical Palliative Care Course. In its 2004 report the INCB commended Uganda’s efforts to improve access to pain treatment, including reforming Uganda’s narcotics control laws so that specially trained nurses could prescribe morphine. 
In recent years, Uganda has significantly boosted its capacity for palliative care. There are now at least 50 facilities providing palliative care services, including morphine.  In order to reach more patients in need, community services for home-based palliative care have been greatly strengthened. The current strategic plan states that all hospitals and health centers should provide palliative care, that necessary medicines should be available, and that palliative care should be integrated into the curriculum of health training institutions. It also emphasizes the need to strengthen referral systems and community-based palliative care. 
Uganda’s significant progress demonstrates the potential for government leadership to rapidly scale up access to palliative care through reforming laws and regulations, increasing drug provision, and encouraging education in palliative care. Many of the Ugandan government’s reforms were carried out in cooperation with NGO representatives and WHO. Government, NGO, and WHO representatives met at a conference to discuss drug treatment availability in 1998, where they made commitments to taking specific measures to improve drug treatment availability. These plans and commitments have translated to many of the country’s achievements today. 
Despite progress, many challenges remain in ensuring access to palliative care throughout Uganda. Some of the nurses trained in palliative care are not using their training because morphine is not available where they work or because hospital administrators are not supporting their efforts, for example, by failing to assign them to care for patients with life-limiting disease. District health departments do not have defined palliative care budgets and inadequate distribution systems for morphine remain a problem.  There is an ongoing need to ensure the availability of oral morphine throughout Uganda; to keep it affordable; prevent stock-outs; and train all relevant healthcare workers.
Human Rights Watch interview with head nurse, Bondo District Hospital, Kenya, March 1, 2010.
 Note that we asked what facilities usuallystock morphine. Stock-outs are common in many African countries. In 2010, Kenya and Uganda both faced interruptions of morphine supply.
Email correspondence with Anne Merriman, director of policy and international programs, Hospice Africa Uganda, June 22, 2010.
Proclamation No. 176/1999 a Proclamation to provide for Drug Administration and Control, s 26(1) available at United Nations Office of Drugs and Crime Legal Library: http://www.unodc.org/enl/showDocument.do?documentUid=2720&country=ETH (accessed January 13, 2011).
 International Narcotics Control Board, “Narcotic Drugs: Estimated World Requirements for
2010: Statistics for 2008,” 2010, http://www.incb.org/incb/en/narcotic_drugs_reports.html (accessed 27 October 2010).
 Jagwe and Merriman, “Uganda: Delivering Analgesia in Rural Africa,” Journal of Pain and Symptom Management.
 INCB, Report of the International Narcotics Control Board for 2004 (New York: United Nations, 2005), pp. 32-33.
 Palliative Care Association of Uganda (PCAU), “Audit Report of Palliative Care Services in Uganda,” April 2009, http://www.theworkcontinues.com/document.asp?id=1386&pageno= (accessed March 27, 2010), pp. 7 and 12.
 Jack Jagwe and Anne Merriman, “Uganda: Delivering Analgesia in Rural Africa: Opioid Availability and Nurse-prescribing,” Journal of Pain and Symptom Management, vol. 33, no. 5 (May 2007); Stjernsward, “Uganda: Initiating a Government Public Health Approach to Pain Relief and Palliative Care,” Journal of Pain and Symptom Management.
Jan Stjernsward, “Uganda: Initiating a Government Public Health Approach to Pain Relief and Palliative Care,” Journal of Pain and Symptom Management, vol. 24, no. 2 (August 2002).
 PCAU, “Audit Report of Palliative Care Services in Uganda,” p. 8.