MORPHINE PRODUCTION SCALED UP IN KENYA

Opioid(s) is term well known to health experts. However, to those that lack any basic training in the medical field; opioid(s) is undeniably a jargon. In essence, these are medicines prescribed to a patient by a doctor to help ease pain. It goes without saying that morphine falls under this category of medicines because it is a very powerful painkiller. It is classified as a strong opioid and placed in step three (step two for children) by the World Health Organization (WHO).
As many as 90% of patients with advanced cancer or HIV/AIDS experience moderate to severe pain, and pain is the second most common complaint of the over 33 million individuals living with HIV/AIDS in the developing world.
The Kenya Ministry of Health (MoH) recognizes that pain needs to be properly assessed and treated using the appropriate medications as recommended by the World Health Organization (WHO) which recommends oral morphine solution for the treatment of moderate to severe pain in both adults and children.
That explains why Kenya Hospices and Palliative Care Association (KEHPCA) has been vocal in advocating for easy access and appropriate use of oral morphine in Kenya. This is because most patients in need of palliative care experience moderate to severe pain and need to be on morphine for pain alleviation.
Therefore, on 19th of April 2017, KEHPCA facilitated the manufacturing of Oral Morphine Solution (OMS) at Kenyatta National Hospital (KNH). During this activity, 1000 bottles of adult oral morphine and 100 bottles of pediatric oral morphine were produced. One may want to inquire why 100 bottles for pediatric morphine? Here is the response; the consumption of morphine by children in Kenya is currently low. The adult and pediatric OMS concentration is 10mg/ml and 1mg/ml respectively.
It is good to note that this is the third batch of morphine being produced. Previously; the first batch was used by patients at KNH while the second batch KEHPCA distributed to a number of palliative care units and hospices in the country. Nevertheless, the bar has been set high this time round; there is an increase in production of morphine. This will be distributed to as many hospitals as possible countywide.
“Our goal is to ensure that patients in need of morphine in Kenya have access to it. That is why this time round we scaled up the production,” explained Dr. Aywak, a pharmacist at KNH.
The manufacturing was made possible by KEHPCA in collaboration with KNH, DANIDA, MOH, Kenya Medical and Supplies Authority (KEMSA), Treat the Pain but to name a few. The morphine produced is of high-quality and consequently appropriate for human consumption.
As morphine and codeine are on the WHO List of Essential Medicines, countries have to provide these medications as part of their core obligations under the right to health, regardless of whether or not they have been included on their domestic essential medicines lists. (Lohman et al.: Access to pain treatment as a human right. BMC Medicine 2010 8:8) http://apps.who.int/medicinedocs/documents/s18774en/s18774en.pdf

Pain management program – a noble course

It is with no doubt that pain is a feeling we all dread. It does not matter whether it is acute or chronic pain, the bottom-line is, we just don’t want to feel it. Let’s take a minute or two and talk about chronic pain. Did you know that this pain does not only affect patient’s body but also has psychological and emotional effects on patients? Yes it does. In most cases when this pain is not treated the patient might end up being depressed. This is the kind of pain most people living with life-threatening diseases experience. One way of addressing this is through advocacy and use of appropriate pain relieving medication. Well,that is exactly what Kenya Hospices and Palliative Care Association (KEHPCA) is doing.
On Tuesday 18th April 2017, we travelled to Thika Level 5 Hospital with a clear objective; to pitch the idea of facilitating a pain management training program. This course targets all health professionals with interest. Some of you may want to find out why target all these people? The undisputed answer is, we all know someone who is going through a lot of pain but sometime we are clueless on how we should help. This training, also called Pain Free Hospital Initiative will therefore do you justice.
Dr. Esther Muinga, the coordinator for relief pain at KEHPCA, while presenting this idea to some of Thika Level 5 hospital administrative staff, outlined some of the topics that will be covered. These include; introduction to pain, pharmacological/ non-pharmacological management of pain, pain in special groups (children, HIV &AIDS and elderly) but to name a few. There are 4 training sessions and each takes 1hour 30minutes. A pre-test and a post-test is done to evaluate participants’ knowledge on pain management.
“This sounds like a noble idea that is worth supporting. Addressing the pain of our patients is a good thing because we never want to see them in pain,” Said Ann Wambugu a senior nurse at the hospital.
They were impressed by this initiative and from May, pain management sessions will kick off. This is the fifth hospital after Kenyatta National Hospital, Machakos Level 5 Hospital, Moi Teaching & Referral Hospital and Kijabe Hospital that KEHPCA is going to facilitate this type of training.
Pain Free Hospital Initiative is supported by Treat the Pain-a program of the American Cancer Society. It is a hospital-wide quality improvement initiative to integrate pain treatment into service delivery and can be replicated in other healthcare facilities. Making pain the fifth vital sign is one of its goals.

NHIF saves you a lot!!

It is a sun-kissed morning and from where I am right now, I can feel the warmth. This is contrary to how I have been feeling these past few days; it has been chilly.Probably, the warmth reflects how today will turn out to be, I believe an epic day.
I have attended day care session at Nairobi Hospice and as usual, nurses, care-givers, volunteers and people living with life-threatening diseases have assembled here. They are ready to do what they do best when they gather; pray together, educate and inspire one another.
National Hospital Insurance Fund (NHIF) representatives are also in the building to share information about this health cover. Everyone is attentive, trying to grasp every detail. Well, wondering who is eligible for NHIF health cover? Anyone above the age of 18, all you need is Ksh500 for registration.However, to have your insurance active; you must consistently pay a monthly fee of Ksh500.
With NHIF, every outpatient is treated for free, while inpatients have their bill paid by NHIF at accredited health facilities. However, there is a limit of how much they can pay for both. In addition, those with NHIF heath cover and going through chemotherapy treatment, have the benefit of going through six chemotherapy sessions without paying even a cent.
“NHIF gives you a lot of a health benefits at a smaller fee. Take advantage of that,” explained Peter, a representative from NHIF.
Therefore, NHIF eases your hospital burden; even with limited finances, you are assured that with this cover one can be treated. You know what? At the end of this educative session anyone who did not have a NHIF health cover has registered for free, thanks to NHIF and Nairobi Hospice.

Palliative care is not a one man’s job

This week’s continuous medical education (CME) session administered by Dr. Asaph Kinyanjui, director of programs at Kenya Hospices and Palliative care association (KEHPCA) found us at Coptic Mission Hospital in Nairobi. The CME session, which usually plays a great role in the sensitization of the public and health care professionals, was one to introduce what palliative care is to the clinicians at the hospital, a facility that is yet to integrate the service in the hospital.

Dr. Kinyanjui enthusiastically started off with an introduction of himself and the organization and then quickly proceeded with the session. One of the topics he sought to address was of terminologies and the unintended consequences that can arise when the wrong ones are used. “In palliative care, conditions should be referred as life threatening because there is always a possibility that it can cause death but also that it can be cured or a person’s life prolonged” stated Dr. Kinyanjui. This was opposed to using terminologies such as “Terminal” or “Life limiting” which often results in a thought that the patient’s life is over no matter the intervention. He emphasized what palliative care is just to remind those in the session that it is an approach that seeks to improve the quality of life of the patients and their families from the time of diagnosis. The quality of life should then always be based from the patient’s perspective, a fact some tend to forget. He urged the clinicians to remember that the patients should always be in the centre of all care, with their needs and goals always coming first .The health care workers perspective, shadowed by a natural bias that may come with being human should not be imposed to patients due to the impropriety it may result to if a patient is misunderstood from the failure of not asking the right questions.

As the CME continued, Dr. Kinyanjui touched base on issues relating to the need to do a full assessment so as to properly approach the patient holistically. “Yes, the patient may be having physical pain, but they may also be experiencing psychological, social and spiritual needs that have to be interpreted in a practical way” said Dr. Kinyanjui. How one communicates with the patients after a diagnosis is made will determine how one copes with the news which in actuality will determine how comfortable their lives will be. He also explained the common misconception people usually have when they hear the term palliative care and the immediate thought that it is care for cancer patients yet there are many other conditions that require palliative services. Palliative care can benefit a lot of patients, not just the ones that are in the last stages of their lives. As one can then assume, it is therefore not one man’s show, it requires a multidisciplinary approach in order for it to be comprehensive.

As the session concluded, Dr. Kinyanjui urged those in attendance to be advocates of palliative care and hoped that soon enough palliative care will be an essential component offered to the patients in Coptic hospital. “Palliative care is a prerogative of every patient. No one has to live or die in pain because we have the adequate measures to alleviate any kind a patient is suffering from.

So let’s all try to be champions of palliative care so as to move Kenya from the preliminary integration to the advanced integration phase and as we continue to work together with the stakeholders involved, we will be able to support our communities.

Breaking the pain cycle

For many years, only one company in the country has been allowed to import morphine and therefore resulting in its distribution being very restricted or better yet, have limited accessibility. Morphine, a true wonder remedy is an opiate type medication, generally found naturally in plants and animals and typically acts directly on the central nervous system to reduce pain. Its wonder medicine portrayal comes from the fact that oral morphine is very efficient in the management of moderate to severe pain while still being relatively inexpensive. Having said that, it is still critical to maintain that many Kenyans continue to struggle with the affordability of the medication due to other financial burdens that come with whichever illness they may be affected by.

Ever since 2009, Kenya Hospices and Palliative Care Association (KEHPCA), the overarching body that supports all aspects of hospice and palliative care throughout Kenya, has been advocating for the allowance of other companies to have permission to import morphine. Great success came in 2011 when two other companies were allowed to import it but that was not enough to ensure that there was accessibility of morphine everywhere in the country. In 2015, based on the procurement of forty-seven kilograms of morphine by the Ministry of Health (MOH) through the support of DANIDA, better distribution to patients will be achieved. As it currently stands, KEHPCA, in collaboration with Kenyatta National Hospital (KNH), Kenya Medical Supplies Authority (KEMSA), the Ministry of Health, Treat the Pain and other stakeholders, the reconstitution of morphine has been achieved with KNH having produced the first batch that passed safety and quality checks and was classified as being safe for human consumption. Treat the Pain has played a key role in supporting the manufacturing of the liquid morphine from the powder procured, for use by government and mission hospitals as well as hospices, being the first time this is happening in Kenya.  The current doctor’s strike has however halted production.

KEHPCA continues to advocate for availability, accessibility and affordability of oral morphine for moderate to severe pain relief but there is still a huge barrier that needs to be crossed. A study done by COCHRANE, a global independent network of researchers, professionals, patients and people interested in health found that morphine taken by mouth produced good pain relief for moderate to severe pain with its effectiveness always standing the test of time. The consumption of pain relief medications such as morphine is however concentrated in a limited number of countries due to the fact that access continues to be based in North America, Western Europe and Oceania. As mentioned by the International Narcotics Control Board (INCB) and Treat the Pain “This imbalance is particularly problematic because latest data available shows that over 70 percent of cancer and 99 percent of HIV deaths actually occur in low and middle-income countries”. As one may assume this is alarming because cancer and HIV/AIDS are merely just the tip of the iceberg when it comes to conditions that usually have pain as a symptom. Pain relief is also needed in other medical situations and ailments such as people recovering from surgery, other pain-causing illnesses such as organ failure and a spectrum of various injuries. As long as access to these pain relieving medications is limited, many people will continue to be denied one of the human rights to which they are entitled to, that being, access to palliative care services. This was emphasized by Dr. Amandua Jacinto, Director of Clinical Services at the Ugandan Ministry of Health during the 5th International African Palliative Care Conference where he said, and “Palliative care must be as available as air.” Pain and symptom management is an important element in palliative care.

The under distribution of morphine in Kenya could partially be due to the stigma associated with the medicine and the fear of potential addiction and abuse in cases of misuse. Health care professionals have however believed it to be worthwhile to use as long as the patients’ pain is accurately assessed, hence the need for continuous public education. Just recently, KNH handed 344 bottles of morphine to KEHPCA for distribution to various palliative care providers to help those currently experiencing moderate to severe pain due to various illnesses.

KEHPCA looks forward to more production and distribution of the medication. This also means that the continuous training of medical professionals in order for proper administration and utilization of the medicine. As mentioned by Treat the Pain, “The problem can be addressed through several approaches including a human rights focus, a policy focus and a training focus”.

The 10/80 Gap

“We are all aging and we may all need palliative care. Diseases are increasing and palliative care services should then be included in our health care services so as to have flourishing lives until the last moment of our lives.” This is the message Dr. Zipporah Ali, the Executive Director, Kenya Hospices and Palliative Care Association (KEHPCA) conveyed to the health care professionals who had attended the continuous medical education (CME) session at MP. Shah Hospital.

The CME session drew out quite a crowd of individuals who were eager to learn about what palliative care is about. Dr. Ali started off the session by explaining what palliative care is and its history both globally and nationally. Palliative care is a specialized care given to people with life-threatening illnesses in the hope of improving their quality of life from the time of diagnosis to whatever trajectory the illness takes. The care consequently usually goes beyond the patient because of its holistic approach which not only focuses on the physical but also supports the patients and their families spiritually, emotionally and psychosocially. It sounds simple, doesn’t it? You may be asking yourself the question, “Isn’t that the care people receive all around the country?” Well, not to a certain extent so. The truth of the matter is, palliative care services, even though a fundamental prerogative for every individual is not always accessible to all Kenyan citizens for various reasons. For instance, it is critical to consider what the WHO commission on the social determinants of health found that “The unequal distribution of health-damaging experiences such as not being able to access needed services is not in any sense a natural phenomenon. The limitations then arise from a toxic combination of poor social policies and programs, unfair economic arrangements and most significantly bad politics,” (2008:1). This is the reason that hospices, who critically rely on charitable support and are integral palliative care providers, still struggle to reach everyone. A matter of fact is that education and training in palliative care is lacking in healthcare professionals, combined with a double burden of the diminished affordability and access for those who need it most.

This is why Dr. Ali continues to advocate and educate on palliative care. The health care professionals were advised to provide continuous palliative care that goes beyond the patient and not be shy to talk about death as it is, in fact, a normal process. Dr. Ali also emphasized the importance of the spiritual element of palliative care especially in our culture which sometimes results in people believing they are bewitched and being punished for some of their actions in life. It is as a result necessary in such situations to carefully help the patients understand their condition which is best done as a team that goes from doctors to nurses, social workers, family members among others. Applying such approaches, therefore, equates to treating the patient and not the disease which is also very critical when it comes to palliative care given to children. “Holding a patients’ hand while engaging in difficult conversations is one of the ways that can ease the tension and make the patient feel valued,” acknowledged one of the participants. He added that the talk was timely and more sessions on communication and pain management should be conducted.

Palliative care reduces suffering, promotes quality of life, supports the caregivers and allows death with dignity. It is not a one size fits all kind of care due to the fact that the pain threshold and the way patients respond to treatment vary. 80% of people who need palliative care services live in low and middle-income countries yet those countries only 10% have access to it. Dr. Ali added that “It’s unfortunate that only 10% or less of the global pain relieving medicines are directed to 80% of the global population who require them.”

Dr. Ali continues to hold the CME sessions because the only way to beat those statistics is through advocacy, continuous education and research.

New beginning

Rain falls like Gods own poetry; each drop is a single letter in a song that takes years to sing. The smell of air was earthy and the dry ground had a watery sheen to it. Cold seeped into my inwards like freezing fog making its way into my bones and wrapping around my brain like a wet blanket. One could not even have words to describe the temperature of the cold morning weather in their vocabulary.

As the nurses and doctors of Ladnan hospital in Pangani slowly walked in the room, their eye bagged eyes showed they had an all nighters shift but were still committed to attend the continuous medical education (CME) session that was facilitated  by Dr. Asaph Kinyanjui from Kenya Hospice and Palliative Care (KEHPCA).

Dr Kinyanjui talked about what palliative care is, who require palliative care and what the essential components of palliative care are. Majority of those present acknowledged that they did not know and therefore needed the information.

World Health Organization (WHO) defines Palliative care as an approach that improves the quality of life of patients and their families facing life threatening illness. This is achieved through the prevention and relief of suffering, by means of early identification, assessment and treatment of pain in addition to other physical, psychosocial and spiritual problems.

People who need palliative care are adults and children suffering from life threatening conditions both communicable and non communicable like; Cancer, HIV/AIDS, Metabolic (DM), Birth asphyxia, Congenital anomalies, geriatric complications, organ failure.

Currently there are 645,000 new cancer cases annually  in Africa and only half of these countries have palliative care services. In Kenya the number of people dying of HIV/AIDS and cancer is 152,000 and 20,000 annually respectively. while that of estimated death in pain each year is 92,000.

Living and dying in pain does not have to happen, therefore Dr Kinyanjui recommend that there is need for community sensitization and integration, strengthening referral networks and  need of advocacy  in  palliative care.

In the end Mrs. Leah Ngatia deputy matron of health services in Ladnan hospital was thankful to KEHPCA for training some of their staff and admits that their hospital comes across many patients who need palliative care. She would advocate for it to be offered in all hospitals.

 

Infinitely journeying on…

While In the quest to advocate for legal aspects in palliative care, Kenya Hospices and Palliative care advocacy officer, Mr Musyoki and Santana, a volunteer, who joined the association recently, accompanied the Coast Hospice team in recording a documentary featuring improved quality of life to the patients and families the hospice serves. The visit to the coastal region in Kenya was rather inspiring particularly hearing and appreciating the work the Coast hospice was doing. During the last day there, the program manager, Mr Eric Onyango, and the social worker of the hospice led us into one of the slums in Mombasa to visit a regular patient of theirs by the name Amina (Not her real name). We made our way into the small but nonetheless cozy home and quickly introduced ourselves to Amina, who flashed her captivating smile and welcomed us.

The nostalgic or what can inevitably be interpreted as the simple times of Amina’s life is quite poignant. Amina and her sisters lost their mother in the year 2000 after which she decided to work as a house help. It is during that time while working that she started getting ill. She described how someone in her life had offered to buy her medication, but did not wholly fulfill that duty which she attributes as a major catalyst in her not healing as quickly as she would have. She later went to the hospital, was diagnosed with cancer, had a treatment plan drawn, which included a referral to Kenyatta National Hospital for radiotherapy and other medication and subsequently made her way to the Coast hospice.

The radiation however gave her side effects which are still quite visible glancing at Amina. Even as we walked in, Amina’s swollen legs were rather perceptible. The Coast Hospice has since been providing her with the pain medication that helps her sleep at night when her legs ache. After going back to the hospital, she was told that she would then need chemotherapy which is greatly expensive. She remembers how she lost what she attributed to be her support system at that time due to the trips she had to make to Nairobi every two weeks for the treatment.

However, she also vividly remembers the open arms that welcomed her and the hospice community she found when she eventually visited. As one can make up, such uncertainty on whether one will get the funds for treatment can in actuality make one feel out of control and inevitably powerless. Amina appreciates her donors, hospice, spirituality and music which are major factors of her life and hope restoration mechanisms. The hospice has given her medication, some funds for travel, the community aspect, extensive psychosocial support and legal advice which has since empowered her. That legal advice she says, makes her not afraid; she is not afraid of mediocre threats because she now knows her rights and proudly voices them when needed. As Amina had stated “Some people have tried to make threats concerning the land I’m currently residing on, but I tell them I have a lawyer and that aspect alone makes them re-think their intimidation”. Her music is her way of voicing her problems, her voice in beating cancer or better yet her fight song.

As we left Amina’s house with vast empathy, a greater appreciation for the benefits of palliative care was put in perspective. The hospice together with the Kenya Hospice and palliative care association (KEHPCA) supports patients as they continue to take back their lives and with the unrelenting support of the community, it is attainable.

The light between oceans

As we entered the Coast hospice grounds, we found the men and women that attend the daycare sessions talking about some of the legal issues they were experiencing. Issues of inheritance and children came about with the Lawyer, Mr. Joseph Lutta providing answers on what the law is on such matters and what should ultimately be anticipated. Mr. Lutta has been a volunteer with the Hospice since 2015. His journey into palliative care started after he researched on the matter and realized that Cancer, which he thought of as a rich man’s western disease was affecting his own community and the legal aspect to it being quite overlooked. His willingness to give a hand in any way he could was further pushed forward after he attended a session and saw people struggling with personal and other legal aspects. Since then, he has found that the patients are quite intrigued to learn about their legal issues and he is constantly trying to merge culture with written law because he does believe that if one is not infected, they are affected.

“I would direct anyone here; it is a place of love, friendship, and laughter. It is not a place to die because if it was that, I wouldn’t be here today but as you see, I am alive and well.” This is what Rebecca; a breast cancer survivor said when she was asked about the hospice. When Daisy (not her real name) was first diagnosed, a natural fear came over her. In her train of thought, she felt like life had now come to its end especially in the event that she would have to undergo a mastectomy. She often reflected on her life during her brief interview and described her journey following the diagnosis, her fight against cancer and remembers the friends she lost but also pure love and heart of giving she has since gotten from the new friends at the hospice. John (not his real name), a prostate cancer survivor also gave a glimpse of his experience with the illness. He also describes how his experience with Coast hospice has been greatly positive, to say the least, due to the new community he is now part of and one that fully understands him. He briefly told us how the Hospice has provided pain relieving medication, needed legal advice, spiritual guidance and staff who wear the counselor hat when the situation calls for it. The team at Coast hospice expressed their commitment to continue supporting patients, most of whom have nowhere else to turn for such care.

As mentioned by many of the patients that we were able to interact with during our visit to Coast hospice, the Hospice and the staff provided a safe space for the patients to release their fears. It was quite an experience and inspirational visiting the hospice when we did.  Kenya Hospices and Palliative Care Association (KEHPCA) has been supporting hospices, including the Coast hospice to integrate legal aspects in palliative care; being a need as expressed by many  palliative care patients. The reminder that the people fighting are our brothers, sisters, mothers, and fathers hit home and in the process epitomized the fact that terminal illnesses are not the end of the world. Daisy, John and the other patients embody the concept of kicking life forward when it kicks you. Among the many important medical and legal services, the hospice provided the friendship and love in which the patients encounter which in it is a healing therapy.

Light at the end of the tunnel

In the outskirts of Mombasa town lies new hope for the people of Changamwe, a bright new dawn. Access to quality palliative care to all who need it.

Bomu Hospital is a social enterprise whose purpose is to provide access to quality healthcare for all, regardless of their economic status. It has been delivering quality healthcare since 1970’s when a group of citizens realized the need of accessible and affordable health care service in the surrounding communities. The hospital provides inpatient, outpatient care, home visits, play therapy for the children, continuous medical health education and has entertainment days for the patients. It serves approximately 1000 patients per month.

In 2012 after intensive research and observation they realized there was need of palliative care services. This was due to the fact that most of their patients who had life threatening illnesses like cancer and HIV/AIDS were not coping well and needed other approaches like;holistic,emotional and psychosocial approach so that they are able to live a normal life.

Some of the challenges they face are limited human resource due to the overwhelming patients and handling children amongst others. Most of the patients come from low resource background and hence most are unable to afford for care. This makes the hospital experience some loss of revenue and cut down other costs in order to support such patients. Speaking to Gaudencia Afwande, a palliative care nurse in Bomu hospital says that “saving a life is more important than money”.

The current doctors strike that has affected service delivery in most public hospitals has led to increase in number of patients being referred to Bomu hospital to access palliative care services making the palliative care unit staff overwhelmed.

Kenya Hospices and Palliative Care Association (KEHPCA) played a big role in supporting the integration of these services by training the staff and educating them about palliative care. Gaudencia is really grateful especially to Dr. Zipporah Ali, the executive director of KEHPCA, who helped her in getting a scholarship to further her education in palliative care.

The palliative care unit at Bomu hospital operates during week days from 8am-5pm and accepts all patients without discrimination.