A Pain Unit with insufficient medicines for pain: the pain of health professionals in Mozambique

Categories: Care.

I watched Dr Emilia  Pinto Miquidade, the Director of the Pain Unit in Maputo Central Hospital as she shared the pain she and her colleagues have to endure every day. She was almost in tears as she shared their experience with me and Ms Lidia Monjane, the National Coordinator of the Mozambique Palliative Care Association (MOPCA). 

The Unit has 2 full time doctors, 3 nurses and 1 psychologist, 2 administrative officers and 3 cleaning assistants. Sometimes it is visited by Anaesthetic doctors. Other staff present at the meeting with Dr Emilia were: Dr Tânia Issufo, a fulltime general doctor at the unit, Mr Thomas Macua, a Psychologist and Ms Sandra Jose, the administrative Officer at the clinic. The Unit is a national referral centre for patients with chronic pain in Mozambique. Dr Emilia noted that the number of patients coming to the unit is reducing due to the lack of medicines and that patients get very disappointed to find the same basic medications that they can access in other health facilities. 

The stock-out of opioids is a serious problem and currently only Tramadol is available and given to only Oncology patients since the amount in stock is not sufficient for everyone, therefore non-oncology patients in pain currently go without it and must look for it in private pharmacies. The unit currently has only one bottle of morphine and again this goes to only Oncology patients while still in hospital. The amount is very limited therefore cannot be given to patients to take home when they are discharged home.

Patient numbers are increasing yet amount of medication given to the pain unit is small. Dr Emilia elaborated this with statistical figures. In November 2014 alone, the unit was given 40 tablets of morphine, yet the monthly need is 2400 tablets. A total of 92 bottles of oral liquid morphine were given per month, compared to the monthly need of 280 bottles. In 2014 alone, the unit received 200-300 new patients looking for the relief of their pain. 

She further explains that for patients with neuropathic pain, medicines such as Amitriptyline and Gabapentin are not available at the hospital. The unit sometimes relies on small donations of medicine from well-wishers. Some epidural techniques and nerve blocks are undertaken for lack of alternatives like morphine, even when they are recommended as one of the last steps. Her pain can be summarised in her words below:

We have our pain ourselves. Sometimes we cry with the patients. By the time a patient comes to the pain unit, they expect something different. We see the patients groaning in pain and sometimes we are helpless. Sometimes it is scary to go near the patients without helping their pain. Dr Emilia, Pain Unit, Maputo Central Hospital

The unit provides pain relief to both patients in the hospital and those outside the hospital. Services provided to patients from their home are more informal (not official hospital arrangement) and the unit had a social worker who would help with patient follow-ups at home and in the community till 2014 when he died. Requesting for another social worker has not yet had results. Yet, the services are needed as the unit currently does not get to know what happens to patients at home and in the community. 

Dr Emilia goes on to note that sometimes the unit receives calls from patients at home but is unable to go to them due to the distances to their homes. The pain unit has established similar units in the 3 regions of the country but there are no pain relief medications thus patients have to come from as far as 2000 Kilometres to the Pain Unit in Maputo and sometimes find the same problem.

The good news is that this pain unit has got the necessary data which demonstrates the discrepancy between what is available and what is required based on patient needs. The unit is making an effort to share such data with the Pharmacy Department of the Ministry of Health which is making an effort to resolve this problem. 

The experiences of Dr Emilia are also reflected in the results of a recent review of national opioids estimation procedures and supply chain mechanisms in three African countries which include Mozambique. The review, which was conducted by the African Palliative Care Association in 2014 with funding from USAID/Regional HIV/AIDS Program (RHAP) in South Africa has provided details of the situation and made some suggestions of what can be done to improve the country estimation of opioids and the supply chain mechanism. APCA and MOPCA are planning for a strategic dissemination workshop of the results in Mozambique before the end of March 2015, with funding support from USAID/RHAP and the Open Society Initiative for Southern Africa (OSISA). 

It is hoped that the key stakeholders and players who can take actions to improve access to pain medications will be part of this dissemination workshop for which APCA will provide additional technical support. There is also more need for awareness creation on the importance of pain relief in achieving the quality of life for the patient and family. More training is also necessary at all levels, including policy, service provider and community level, and specifically for the staff of the pain unit bearing in mind that some of the earlier trained health professionals have moved on.

APCA’s experience working in Mozambique since 2006 is that the local partners are very committed to serving patients and families; are reliable and transparent. MOPCA which has been APCA’s main local partner has established a very strong relationship with the Ministry of Health (MISAU), the Maputo Central Hospital where it is housed, the Association of Nurses in Mozambique (ANEMO) and the Pain Unit, among others. Together they have been able to realise important milestones for the future of palliative care and pain management in the country using the very small funding from APCA over the last few years. Such milestones include: the development of a National Palliative care policy which has been disseminated to all the 11 provinces in the country; the development of a national palliative care training curriculum and accompanying training materials; strengthening of MOPCA to support local coordination of palliative care interventions and maintenance of a national technical working group for palliative care.

The Ministry of Health in Mozambique (MISAU) is very committed to the integration of palliative care in the health system, but as Dr Aleny, the Head of HIV/AIDS Department of MISAU notes to APCA, it does not have sufficient funding this year for allocation to palliative care. Efforts are being made to integrate palliative care and pain management in Mozambique’s economic and social plan of the next financial year (2015/2016), following its inclusion in the National health strategic plan which is currently under development and the fact that the country now has a national palliative care policy with funding from USAID/RHAP and OSISA. 

Dr Aleny shared concerns of the rapidly changing funding environment that is seeing critical civil society organisations that are complementing Government in health service provision close, which is a threat to health systems. She noted the need to bring on board the Global Fund to support palliative care interventions and regional blocks such as Southern Africa Development Community (SADC), as key players in influencing regional commitment to palliative care, taking into consideration the May 2014 World Health Assembly Resolution on palliative care. She emphasised the need to use regional data and operational research findings from APCA in further advocacy for palliative care and pain management.

It is obvious that Mozambique, the only Portuguese country so far in Africa which has made advancements in integration of palliative care in its health system needs further international, regional and local technical and funding support. This will enable the country to sustain the gains over the last few years as well as use them as a springboard for national scale-up of palliative care and pain management services. The country is the 3rd of the six African countries with approved national palliative care stand-alone policies, after Rwanda and the Kingdom of Swaziland, recently joined by Tanzania, Zimbabwe and Malawi. Mozambique has great potential in supporting the development of palliative care and pain management programmes in other Portuguese speaking countries in Africa, a critical reason for strengthening its further capacity.


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