APCA's work to adapt palliative care to the African context takes place against a constantly shifting backdrop of issues and factors that affect care delivery. Among the key issues and opportunities we're constantly monitoring and taking into account as we shape our strategies are:
The explosion in lifestyle-related diseases
Changes from traditional plant-based diets towards processed western-style foods, increasing use of motorized transport even in very rural areas and the move away from an active farm-based life towards sedentary desk-based work, are resulting in an enormous increase in lifestyle-related diseases such as cancer and diabetes among others. These diseases are long-term and require chronic comprehensive care including palliative care, so it's vital that strong delivery systems be put in place before the rise in these diseases incapacitates the African population.
'Task-shifting' across medical professionals
Access to palliative care services (especially in rural areas) could be greatly increased if a wider range of health care professionals was trained and permitted to deliver aspects of holistic care. Africa's doctor-to-patient ratios are so imbalanced that if it's only doctors who are legally permitted to prescribe medication such as morphine, antiretrovirals and antihypertensives there's no hope of reaching most of the population in need of comprehensive chronic care including palliative care. Some countries are following Uganda's example and changing existing legislation to allow some doctors' roles to be 'shifted' to specially-trained nurses – for example, enabling them to prescribe oral morphine to patients in moderate to severe pain. Advocating for more countries to follow suit is an important part of APCA's work to ensure the right regulatory framework for palliative care delivery.
The rising need for palliative care in children
In light of the AIDS epidemic and paediatric cancers, the need for palliative care for African children is disproportionate – whether for themselves, or to help them cope with caring for and losing sick parents. In 2007, 1.8m children in Sub-Saharan Africa were living with HIV/AIDS, some 240,000 deaths reported and many more children orphaned. Statistics for child cancer deaths aren't available, but these are also likely to have been significant.
Children's special needs are easily neglected, as it's often the same nurses or carers who give palliative care to children and adults. But the 'one-size-fits-all' approach doesn't work with palliative care. Children have different needs from adults. Their varying stages of development affect their understanding of their illness; they are not legally able to consent to medical treatment; they may lack the language, confidence or skills to express their needs or pain. On the medical side, as well as a lack of understanding of the disease process in children, there is often restricted access to paediatric drugs. Severe poverty also forces parents to make tough decisions on who receives finite resources, and Africa's many child-headed households need special support.
Women's roles
Issues of gender and power in the society affect women's access to palliative care. They may often be economically dependent and have limited control over end-of-life preferences and access to information about their illness. They're often the primary carers in a family, so they shoulder a disproportionate burden if a relative falls sick, and can conversely be left without proper care when they're the ones who are seriously ill. It's vital that as more girls are educated and enter the paid workforce, so they have more independence and a better understanding of their rights. APCA also works specifically to make women fully aware about palliative care – both for themselves and for their families.