A very poor country, with an under-resourced health system, Uganda has become an example of best practice in developing countries for promoting palliative care and improving access to morphine. Katherine Pettus, PhD, joins home visits with a Hospice Africa Uganda (HAU) nurse and witnesses the experiences of Ugandan patients.

12 Aug 2015

Katherine went on home visits with Joyce, the Hospice Africa Uganda (HAU) nurse who let her accompany her on rounds that Saturday morning. She met Jane, who is caring for her husband Joseph, bedridden with advanced cancer, in a village on the outskirts of Kampala. 

Joyce had brought Jane a refill of oral morphine, the “gold standard of pain relief” according to the World Health Organisation, so she would have enough for the coming week to give Joseph.  A powerful medicine controlled under international law, morphine is unavailable in many countries because of its reputation for being “addictive,” and causing respiratory failure. 

A Nairobi based pharmaceutical company called Ripple currently imports the powder from Hungary, where ironically, oral morphine is not available for palliative care. Ripple is one of the few pharmaceutical companies that cares to jump through the regulatory hoops necessary to import and sell morphine, which because it is not under patent, and sales are uncertain, has a very low profit margin.

Moreover, and this is key to why Jane’s husband had pain relief delivered to his door that morning: not only has the Ugandan government committed to subsidising morphine imports, so that the medicine is free to patients — it has authorised nurses such as Joyce, who have qualified after taking a specific training, to be nurse prescribers.  Uganda is the only country in the world that allows nurses to prescribe morphine. With a doctor patient ratio of 1/25,000, this sort of task shifting is key to expanding pain relief, although the nurse patient ratio also stands at an astounding  1/11,000.  

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Without the leadership, passion, and commitment of palliative care advocates on the ground, and their allies in government and the pharmaceutical industry, the politics and economics of importing, manufacturing, distributing, and prescribing morphine can be complex and daunting.

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