‘Freedom from pain should be seen as a right of every cancer patient and access to pain therapy as a measure of respect for the right in Lesotho There are several barriers to effective pain control in both A focus on essential pain medicationaccessibility and Pain management cancer and / or HIV/AIDS. Such barriers could be patient related; clinician-related; societal/health system; and political and/or legal-related.

1. Status of Palliative
Care in Lesotho
A focus on essential pain medication
accessibility and Pain management
Sejojo Phaaroe
Google+
President of LBCN
Policy, Palliative care and Cancer Advocacy-
-APCA

2. Presentation layout
 Goal
 Concept of Palliative Care and its principles in Cancer patients
and people with chronic illnesses .
 continuum of care and pain management in Cancer
 Tools for palliative care assessment and management
 Psychological aspects of Palliative care
 Structures in place for strengthening Palliative care regionally
supporting Lesotho otho response/status of Palliative care
 Opiods availability
 Achievements
 Challenges
 Way forward

3. Advocacy
• *Palliative care services in a programme
must be designed to enable change by
providing Health professional and
communities with tools that encourage and
support those with terminal illnesses like
cancer to live a functional and productive
life- These are our People *- Sejojo Phaaroe
2008

4. There is no need to catch the Ball if you do not Know
where you are and- where you are going

5. Concept
• •Palliative care is the total care of individuals
with incurable diseases, and their families,
and embraces ….:
• •all physical,
• •Emotional
• •Social
• •Spiritual needs,
• • rather than purely Medical needs

6. Palliative care involves
• •Appropriate use of a range of therapies which do
not aim to cure, but rather help to control
symptoms, and preserve quality of life while
minimizing adverse effects
• •Supporting the family and friends of the patient,
and involving healthcare personel, other
professionals and the community members who
are skilled in communicating & helping with the
psychological and social dimensions of the illness
• •Giving individuals with cancer and their families
control over their own treatment and involving
them in care management decisions.

7. Palliative care
• Provides relief from pain and other distressing
symptoms;
• Affirms life and regards dying as a normal
process;
• Integrates the psychological and spiritual
aspects of patient care;
• Offers a support system to help patients live
as actively as possible until death;

8. Distinctive features of palliative care
• A younger affected age group in extremely emotive issues
such as sexuality, death, reproduction, guilt and loss of
vitality
• Multisystem disorders more common- more than one
disease process may be occurring.[
• More variable disease patterns-
• care givers must be aware of a range of new presentations
of other diseases e.g Anemia
• MORE UNPREDICTABLE TERMINAL PHASE
• Greater use of multiple drug treatments, with many new therapies
emerging
• Higher incidence of psychosocial problems- with often the worry of
young families and loss of income and unfinished business

9. Palliative care and Pain Management
across the continuum of cancer care
Diagnosi
s
Death
Palliative Care
Treatments
aimed at
prolonging life
Continuum of
Care
Palliative care & Pain Mgt across the
continuum of care
Bereavemen
t

11. Classification of Pain
• Pain is generally classified as either
norciceptive or neuropathic.
• Norciceptive pain is caused by tissue injury
resulting in direct stimulation of intact
afferent nerve endings and it is either
• somatic or visceral.
• Somatic is usually well localised (described as
dull, aching, throbbing, sharp, or gnawing in
nature) whereas visceral pain is usually poorly
localized (described as deep, aching, crampy,
or a sensation of pressure).

12. Neuropathic pain
• is as a result of damage to the nerve pathways and a
normal stimulus can result in an abnormal response.
• The pain may exceed observable injury and it is typically
described as burning, tingling, pricking, shooting,
stabbing, electrical, crawling insects, etc.
• Neuropathic pain is present in about 40% of AIDS patients
the most common being painful neuropathy –
predominantly sensory neuropathy (PNS).
• It is now known that several antiretroviral therapies
(ARVs) e.g. Didanosine [ddI], Zalcitabine [ddC] and d4T,
among others, can cause painful toxic neuropathy.

13. Pain in Cancer
• Ninety percent (90%) of patients with
advanced cancer experience severe pain, with
pain occuring in about 30% of all cancer
patients, regardless of the stage of the
disease.
• More than 50% of cancer patients may be
undertreated for their pain and we need to
remember not only that pain is rarely a sign of
early cancer but that pain usually increases as
cancer progresses
• Because of angiogenessis

14. • Most common cancer pain is as a result of tumors
spreading to bones (bone metastasis).
• About 60-80% of cancer patients with bone
metastasis experience pain.
• The second most common cause of cancer pain is from
tumors infiltrating nerves and / or hollow viscuses.
• There is increasing evidence that tumors near nerves
tend to cause the most severe pain.
• The third most common pain associated with cancer
occurs as a complication of treatment given to treat
the cancer: chemotherapy, radiation, or surgery.
• More than 80% of patients with cancer experience
more than one distinct pain and this poses a great
challenge to clinicians to effectively treat chronic
cancer pain since each patient’s pain is unique.

15. Psychological aspects of palliative
care
• Anxiety and depression are common in Cancer patients
• Signs include restlessness, insomnia, shortness of
breath, numbness
• These can overshadow the psychological signs in
patient with advanced disease
• A referral to a psychiatrist or other mental health
professional when ever depression is suspected.
• Supportive psychotherapy and good listening is a good
palliative practice
• formal psychotherapy programmes need to be
established

16. WHO- The “Total” Pain
Concept
Spiritual
Emotional
Financial
Physical
•Guilt
•Why me?
•Life closure issues
•From disease
•From treatment
•Direct costs
•Indirect costs
•Loss of function
•Coping abilities
PAIN
opioids?

17. CANCER PAIN RELIEF

18. Comprehensive review of international conventions on
cancers
• IUAC ( International union Against Cancer)
• IUCR ( International Union on Cancer Research )
• IAC (International Academy of Cytology)
• WHO (2002) -
•
• AFROX declaration (2007)
• …AU ( Maputo SRH declaration)
• …SADC
• …Lesotho Road map ( Maternal Mortality SRHR)
• WHO
2. Lesotho RH Cancer Screening Guidelines WHO, 2002

19. Regional response
•Resolution 58.22 of the 58th World Health Assembly
echoed resolution 2005/25 of the UN’s Economic and
Social Council (ECOSOC), thereby recognising the
importance of improving the treatment of pain using
opioid analgesics and calling upon Member States to
remove barriers to ensure their medical availability.
•In an effort to advance these resolutions and to promote
the availability of essential pain medicines in Africa,
•Intensify palliative care services
•APCA held a regional essential pain medication
accessibility workshop for the southern Africa region in
February 2008

20. Selection criteria•Senior / Chief pharmacists;
•Drug regulatory authority and / or National Competent Authority
representatives;
•National Registrar of Drugs;
•Pharmacy Board / Council representative;
•Ministry of Health (MoH) clinical services and / or policy personnel;
•Palliative care providers – persons actively providing care;
•Senior physicians and senior nurses from teaching institutions;
•Representatives from the drug enforcement agencies;
•Heads of respective oncology , pathology and / or HIV/AIDS
treatment/ care units.
•Psychologists, and Clergies
It was emphasised that the selected participants had to be willing to continue
advocating for policies that would make palliative care and essential palliative care
medicines, including opioids, available and more accessible in their espective
countries

21. SADC- Country teams
• INTRODUCTION OF THE COUNTRY TEAMS
• Lesotho
• Botswana
• Mozambique
• Namibia
• Kingdom of Swaziland
• Zimbabwe
• South Africa

22. African Palliative care support structures

23. ABOUT THE AFRICAN
PALLIATIVE CARE ASSOCIATION
• African Palliative Care Association (APCA) was
provisionally established in 2002, formally
established in 2004, to be a catalyst for the scale-up
of quality palliative care services across Africa.
• The mission of APCA is to promote and support
culturally appropriate palliative care across the
continent for people with progressive, life-limiting
illnesses, such as cancer and HIV/AIDS, through
education, training, advocacy
• development of standards of care, using a culturally
appropriate public health approach that strives to
balance quality with extended coverage.

24. Objectives of APCA
• APCA’s broad strategic objectives are to:
• Promote the availability of palliative care for all in need,
including orphans and vulnerable children (OVC);
• Encourage governments across Africa to support
affordable and appropriate palliative care and to have it
incorporated into the whole spectrum of existing health
care services;
• Promote the availability of essential palliative care
medicines (especially opioids) for all in need;
• Promote palliative care training programmes suitable for
African countries;
• Develop and promote quality standards in palliative care
training and service provision for the different levels of
health professionals and care providers;

25. Palliative care Quality systems, and process control

26. Why Advocacy- remove
Barriers effective pain control
 Patient related
 Clinician related
 Health system related
 Political related
 Cultural, religion, believes,
attitudes
 Lack of knowledge on
palliative care, attitude,
 Lack of services, lack of
coordination of supply chain
 Lack of policies over opioid
regulation, dispensing for
nurses, prohibition at level 1

27. WHO- Public Health
(Stjernsward, 2007)
Oncology ?
problem
Lab
tests?

28. Lesotho Country Team on Palliative
Care
Study

29. Treaties bind the entire government
• Treaties are signed by a government official on behalf
of the entire nation.
• the entire government is obligated to achieve what is
agreed on in any convention whereto a country is a
signatory.
• In case of public health issues, this responsibility is
not restricted to the Ministry of Health or even to an
individual civil servant.
• Also other ministries, including the Ministry of
Justice, the Ministry of Defence, the Ministry of
Police, or whatever ministry is involved in drug
control in a country should be dedicated to a treaty’s
objectives and obligations.

30. The Kingdom of Lesotho
• Mountain Kingdom’, gained independence from the British in
1966.
• It is a landlocked country completely surrounded by South
Africa.
• Lesotho is mountainous, with more than 80% of the country
being 1,800 meters above sea level.
• In 2007 the population of Lesotho was estimated to be 1.8
• million compared to 1.9 million in 2004.
• The population growth rate is 0.14%, with 70% of the population
being rural.
• The total life expectancy at birth is 40 years.
• The country is divided into 18 Health Service Areas, of which 10
are government owned and 7 are owned by the Christian Health
Association of Lesotho. The doctor-to-population ratio is
1:16,298, whereas the nurse-to-population ratio is 1:2,226.
• The national literacy rate is 90.3% for females and 73.7% for
males.

31. Situation as at 2008
•HIV and AIDS Control Policy, or the National Medicines Policy
of 2006. The Lesotho Standard Treatment Guidelines 2006
do not include palliative care either.
•However, the Drugs of Abuse Act is presently before Parliament and the
Medicines Bill is presently in draft form.
•The National Drug Policy 2006 addresses medications in general
without specifying classes (e.g. opioids).
•Most healthcare professionals (physicians, nurses, social workers,
pharmacists, and spiritual workers) are not well informed about the
concept of palliative care.
•Some of the nurses trained in IMAI and IMCI have familiarity with but
limited understanding of palliative care.
•All physicians are trained outside of Lesotho, many of whom are
foreign with language barriers and limited knowledge of culture

33. S.Phaaroe et al
S Phaaroe etal 2007
66.7: 100 000

34. Cancer Situation in
Lesotho
 Cervical – 40.9% - (ASIR – 66.7:100,000 (LES);
(S. Phaaroe e tal MOHSW/WHO 2007)
 Breast – 18% of all cancers
 Prostrate – 13.5%;
 Skin – 12.6%;
 Lung – no estimates ( found on autopsy);
 Leukemias/lymphomas – no estimates;
 No cancer treatment centre; but we are strongly
working on it to be established urgently
 Cancer for angiogenesis

35. Pain Control barriers in Lesotho
•‘Freedom from pain should be seen as a
right of every cancer patient and access to
pain therapy as a measure of respect for the
right in Lesotho
•There are several barriers to effective pain
control in both cancer and / or HIV/AIDS.
Such barriers could be patientrelated;
clinician-related; societal/health system;
and political and/or legal-related.

36. Examples of the various palliative care
models not available in Lesotho are:
• Home-based care;
• Outpatient care;
• Outreach services (e.g. roadside clinics);
• Hospital-based palliative care teams;
• Day care;
• Hospice inpatient care;
• And workplace programmes.

37. Palliative care service management : Patients
should always referred to these services
• Health education : Clarify temporary aspects of
pain; acute or chronic
• palliative care advocacy focus on essential pain
medication system
• Symptom management
• Pain management
• Diet management
• Non pharmacological activities –rehabilitation,
physical / recreational activities, music , bathing,
stress management ( comedies, , acupuncture,
ocean music, meditation, motivational Talks etc)

38. Dietary guidelines to try and
prevent disease include
• Control weight and obesity
• Reduce consumption of total fat <30%
• Increase fibre intake
• Minimize consumption of salt-cured, salt-
pickled and smoked foods
• Consume alchohol beverages in moderation
if at all.
• Immune factors may interfere with
recognition of tumour cell as foreign
•pain,
weakness,
• loss of appetide,
•early satiety,
•constipation,
•dry mouth,
•dyspnea

39. The patient ‘s wishes
• •It is extremely important to involve
individuals with Cancer in the clinical decision
making process wherever possible
• •This will give them a sense of control over
their own life
• •Many cancer patients decline certain
investigations and therapies, but take strengh
from doing so
• •The wishes of the person with Terminal
diseases like AIDS and Cancer should always
be respected as far as is ethically possible

40. • Advocacy Namibia Workshop Report.pdf

41. Medicine Formulation Strength
Pethidine Hcl Parenteral 50mg/mL
Morphine
sulphate
Tablets 10mg
Morphine Parenteral 10mg/mL
Fentanyl Parenteral 100mcg/2cc
Tramadole Tabs / caps 350 mg
Opioids Available in Lesotho are:

42. Pain and transduction
opioid, and various other substances (e.g., codeine, oxycodone, hydrocodone,
dihydromorphine, pethidine) all exert a similar influence on the opioid receptor
system

43. Opioids availability
• Other formulations that are needed include
morphine powder for reconstitution into
liquid, as well as different tablet strengths of
morphine.
• In Lesotho there are no cost implication issues
since all medicines are subsidised by the
Government of Lesotho, with the only
healthcare charge being for hospital
consultations

44. • Opioids are bought from South Africa and abroad with
only two in-country wholesale distributors: the National
Drug Service Organisation (NDSO) and TriPharm (a
private company).
• The Ministry of Health (MoH) is responsible for issuing
importation permits, and endorses supplies received by
the NDSO and orders made by public and private
hospitals.
• In order to prescribe opioids, physicians only need to be
actively licensed to practice with no need for separate
licensure.

45. challenges and barriers to opioid accessibility in
Lesotho
• 1. Inadequate, untimely and under-reporting from distributors
to MoH thereby affecting estimates sent to INCB leading to
stock-outs;
• 2. Inadequate training of MoH (the national competent
authority) in estimating and reporting to the INCB;
• 3. Rapid turnover of staff in the Medical Competent Authority
with poor continuity;
• 4. Lack of recommended opioid formulations and dosage forms;
• 5. Limited opioid availability for paediatric prescribing;
• 6. Opioid prescribing is limited to hospital settings (urban and
rural) and urban clinics;
• 7. The mountainous terrain inhibits easy access for rural dwellers
to medical facilities;

46. Limited use of Pain assessment tools

47. Pain management needs• Reassure the patient and the family that pain can be relieved.
Power of words, trust and empathy
• Explain that pain relief is not instantaneous.
• Explain that unpleasant side effects will wear off after 3 days.
• The goal of pain management is to ensure that the patient is—
• Pain-free at rest.
• Pain-free at night.
• Pain-free while active.
• Use step-by-step approach to pain relief according to the WHO
analgesic ladder . The principles governing use of
analgesics are that they should be given—
• By mouth
• By the clock
• By the ladder
• By the patient
• Reassure the patient of regular visits and reassessment by
health care professional.
Mild
pain
Aspirin
ibuprofen
Acetamin
ophen
+-
adjuvants
Moderate
pain
Codeaine
Oxycodain
e
Dihydroco
daine
tramadole
+-
adjuvants
Severe
pain
Morphine
Hydromor
phine
Methadon
e
Levorpha
nol
Fentayl
Oxycodai
ne
+-adjuvants
• 3
2
1

48. Strengthen Overall Pain Management
Strategy
• Empathy , care and support, Alternative
techniques in managing spiritual, emotional,
and social problems may require referral to
social worker or other people (medical or
nonmedical).
• Determine the aim of treatment plan.
• Decide on which analgesics to use first or
treatment implementation /course.
• Determine any adjuvants (i.e., co-analgesics)
that may be needed to counteract side effects
of the analgesics.

49. No- Rehabilitation services/ centres
• Cancer Rehabilitation
• goal is to improve daily function and quality of life for the
cancer survivor
• Fatigue
• Weakness
• Poor endurance
• Decline in balance
• Postural changes
• Joint stiffness
• Pain, pain, pain- PALLIATIVE CARE (body, mind,soul)
• Numbness in feet or hands
• Balance disorders
• Bladder and bowel management
• Multiple sclerosis
• Numbness and tingling
• Paralysis
• Parkinson's disease and other movement disorders
• Pulmonary disorders
• Sensory disorders
• Spasticity
• Speech and swallowing disorders (including apraxia)
• Walking difficulty
NO - HOSPICE
SERVICES

50. Corrective actions
1. Country strategy submitted for approval to DGHS
2. Approval of Technical Team and TOT Trainings to expand
team carried In and Outside Country
3. Trainings of Pharmacists and Pharmacy technologists on
Palliative care and in estimating and reporting to the
INCB; to include Private Pharmacies
4. Curriculum review and in -cooperated in Health training
institutions
5. Training of health training institutions tutors on Palliative care
6. APCA Coordination office was established in Lesotho
7. Advocacy and awareness activities , IEC, FLYERS
8. Palliative care Presentation LMA, - Mr Sibusiswe Dlamini
Swaziland-

51. Lesotho Trainings
9. By Hospice Lady brand and APCA
10. Island Hospice Service and APCA
12. By Trainings – HPCSA and APCA
13. By Ms Sethembile Dlamini – Trainings for Nurses
Swaziland
14. Dr Jenifer Johnson – USAID / SADAC Coordination-USA/
Swaziland
15 Training of health professionals on Palliative nurses –
Workshops , NORTH, SOUTH, CENTRAL
16. Working with a physician provider and independently provided individual and
family assessment and care planning, adjustment counseling, grief counseling,
advance care planning and long term care planning. At HOME BASED VISITS
Island Hospice Service

52. trainings

53. Follow up Achievements/ Strengths
• Report of Namibia Feb 2008.doc
• ......Sejojo PhaaroeDesktopPALLIATIVE
CARE IN LESOTHO 5.doc
• NCDs strategic plan inclusive of palliative care
• Baseline assessment done-( reveals that there
are no PALLIATIVE CARE services in Lesotho)
• VHA policy in place
• Need for Palliative care well articled in the
NCD.s strategic plan and implantation plan
• Palliative care is on the Political Agenda

54. Community Based, multidisciplinary palliative care
Physician Initiate care plan
Oncology .
Palliative Nurses
and other nurses
Case MGT, monitor
RX
Home care Aides Bathing, toilet,
meal preparation
Social worker Psychosocial issues
Rehabilitation
therapists
Exercises,
environmental
adaptation
Psychologists, clergies
Spiritual care , church
groups, counselors
Spiritual, psychosocial,
nutrition

55. Palliative care Results Frameworks
5
Goal: Improved Health Status
And Palliative care
Objective: Improved Use of Palliative care medicines, pain assesment and management s
R1: Access/Availability R2: Quality R3: Sustainability R4: Demand
R1.1:Commodities/Facilities
R1.2: Equity
R2.2: Provider Performance
R2.3: Training/Supervision
R2.4: Information System
R3.1: Policy
R3.2: Health Care Finance
R3.3: Private Sector
R4.1: Attitude
R4.2: Knowledge
R4.3: Community Support

56. a Case for Palliative care M&E
The Legs (Programme Implementers):
Coordinate Implement of projects, spend the
budget, report on results and leave footprints of
the organisation in the community.
The Arms and Spine (M&E
Champions):
Standard bearers of M&E Values and
principles, concepts, methods, tools
.
Head (Senior Management):
Org Brain Machine)
Sets the Agenda. Eye, Nose, and Ears and Mouth
of the Org, break the silence

57. THE ROAD AHEAD NOW IS NEARLY CLEAR

59. Sejojo Phaaroe – Kabelo Mputsoe Cancer Radio Oncologytherapy centre

60. YES WE CAN!!!!!

61. Thank you
for Listening
thinktankentr@gmail.com
+266 50468036