Good morning Africa Briefers,

This week, we take a closer look at access to opioid painkillers across the continent, following recent coverage of a Ugandan Ministry of Health report that states that the vast majority of people in need of palliative care, of which pain relief is a central part, are not able to access it. We’ll discuss some of the details of this story, before examining the wider context of Africa’s opioid crisis - one defined by the lack, rather than the abundance, of opioid painkillers. We’ll then reflect on some of the structural barriers to resolving this issue, and describe some of the efforts to tackle them.

Last weekend, in recognition of World Hospice and Palliative Care Day, the Director of the Palliative Care Association of Uganda (PCAU), Mark Donald Mwesiga, spoke to media and gatherers at an event in the Ugandan capital of Kampala. Mwesiga shared with attendees recent findings from a Ministry of Health-commissioned study that found that 89% of the roughly 500,000 Ugandans currently in need of palliative care were unable to access it (Daily Monitor).

Mwesiga lamented the fact that such care lacked its own specific budget in the Ugandan health system, and was instead funded only as part of primary care. Representatives from the national Ministry of Health present at the event pledged to increase their spending on palliative care by 7% over the coming years to target this major hole in public health services (The Independent; Daily Press Uganda).

However, with non-communicable diseases on the rise in Uganda, as elsewhere in Africa, demand for palliative care and painkillers will only increase, with rising cancer rates a particular concern for policymakers, clinicians, and patients due to the long-term nature of treatment for pain and symptom management of these diseases (Nature; Al-Jazeera).

Uganda is not the only country in Africa that suffers from limited access to pain relief. In Nigeria, only 0.2% of national morphine demand is met, while Canada has enough to accommodate 3,000% of its needs (The Guardian). In lower and middle income countries (LMICs), of which a great proportion are African states, around 20 million people die each year in severe pain without strong painkillers (The Lancet), with this number growing. Only 3.6% of globally available opioid painkillers go to LMICs, and only 0.03% to low-income countries. Despite this, 80% of those in urgent need of palliative care globally live in LMICs (EJSO) - evidence of an enormous gap in supply.

Over the past few years, various articles have described what this situation looks like on the ground. Last summer, The Guardian reported on the lack of access to opioids in Ethiopia, where the conflict derailed already fragile and limited supply chains. They described the vast numbers of people suffering quietly from advanced, painful forms of cancer and living without access to pain relief. Quoting the Director of a hospice in Addis Ababa, the report notes chillingly that some patients have asked clinicians for euthanasia, rather than continue living in such significant and untreated pain.

In 2019 meanwhile, NPR described in graphic terms the realities of conducting orthopaedic surgery in the Gambia with only very limited access to anaesthesia and pain relief, quoting one doctor as saying he had to leave the ward during post-surgery dressing changes because he couldn’t bear listening to the screams of his patients. Other reports from across the continent including Senegal, Malawi, Botswana, and Morocco tell similar, gruesome stories.

The limited access to opioid painkillers across much of Africa has a very wide variety of causes. As the late, great Paul Farmer observed, African health systems often lack the staff, space, stuff, and systems required to deliver high-quality and wide-reaching care, due to a whole host of reasons, from the legacies of colonialism, to the disease-specific ways in which aid funding for health issues has historically been targeted, and to the limited expenditure of many African governments on health.

As a consequence of these larger, structural factors, many people do not know palliative care and pain relief is available in some clinics, while others are not able to travel from their homes to hospitals that provide it. Even for those that can make it to a clinic for care, many are unable to afford medications or diagnostic scans for their health conditions, making pain relief and condition management difficult. Others meanwhile are misdiagnosed or prescribed inappropriate drugs, sometimes because clinicians are not comfortable prescribing high-strength and potentially addictive painkillers in the absence of highly-trained palliative care specialists or anaesthetists (The Guardian).

Another important aspect of the shortage in opioids is the international regulatory frameworks that govern them. Amidst fears of a U.S.-style opioid epidemic in Africa, global health institutions have historically been ambivalent about the widespread rollout of generic opioid drugs across the continent, meaning that governments and international organisations alike have been slow to prioritise access to pain relief in African healthcare settings (The Conversation; Usman 2020). Nonetheless, these regulations are changing, albeit slowly (The Conversation).

African governments have increasingly started to take pain relief more seriously across the continent. Returning to Uganda, the Ministry of Health was the first country in Africa to roll-out a programme that aimed to make a low-cost morphine solution available to the majority of the population, consisting of a powdered form of the drug mixed with water then drunk by patients (NPR; NPR; WHO). While in practice this has not been fully implemented, the idea to focus on low-tech, low-cost, morphine-based opioid treatments has been taken up elsewhere, such as in Rwanda, where it has been highly effective (Voa; JPSM).

Such efforts by national governments will likely only increase in the coming years, as the burden of non-communicable diseases in Africa grows rapidly and the demand for palliative care and pain relief amongst citizens grows with it. Shifts in global health and international development spending towards universal health coverage, health systems strengthening, and pharmaceutical supply chains will likely support efforts to supply this growing demand. Alongside this, many African governments - sick of shipping out money to large generic manufacturers in Asia - are also trying to find out ways to domesticate the production of pharmaceutical products, with painkillers likely to be an important focal point in years to come.

Africa’s demand for packaged medicines is worth $18 billion a year — but 61% of these goods are imported, and just 3% met by intra-African trade. However, under the African Continental Free Trade Area agreement, fragmented regulatory systems will be harmonised and intra-African trade in medicines and pharmaceuticals is set to grow, with business increasingly aware of these opportunities. According to the World Economic Forum’s AfCFTA: A New Era for Global Business and Investment in Africa report, companies like Novartis are already taking notice of the growing opportunities African pharmaceuticals present.

That’s all from us this week!

Cheers,

Josh