United Against Cancer v2: Dr. Luyirika and Zainab Shinkafi-Bagudu on Palliative Care in Africa

In this episode, Dr. Emmanuel Luyirika, a renowned leader in African palliative care, is interviewed by Zainab Shinkafi-Bagudu. Dr. Luyirika shares his extensive experience in improving palliative care services across Africa, emphasizing care integration, policy development, and innovative funding solutions. Learn about the challenges and strategies for enhancing palliative care in low- and middle-income countries and how leveraging data can improve cancer treatment and patient outcomes.

Dr. Zainab Shinkafi-Bagudu is a global cancer advocate, a pediatrician, a UICC Board Member, UICC President-Elect 2024-2026, Founder of the Medicaid Cancer Foundation, and the Chairperson of First Ladies Against Cancer (FLAC). Dr. Bagudu is working with the state ministries of health, education, and women affairs to implement programs to sustainably improve menstrual hygiene, girl-child education, economic empowerment of women, and put an end to gender-based violence. Zainab Shinkafi-Bagudu is a member of the Editorial Board of OncoDaily.

Dr. Emmanuel Luyirika is the Executive Director of the African Palliative Care Association, a pan-African organization focused on palliative care initiatives in multiple African countries. He serves as a board member of the Worldwide Hospice Palliative Care Alliance. Dr. Luyirika is a co-investigator in ongoing palliative care studies and has conducted research on HIV, cancer, and palliative care. He has also served on Data Safety Monitoring Boards and technical steering committees for various research projects in Africa. Additionally, he is a co-author of several chapters in books related to cancer and palliative care.

Zainab Shinkafi-Bagudu: So, a very wide range there, contributing to governments, contributing to workforce capacity, benefiting the patients, partnerships both in country and out of the continent, and so much more. You mentioned a lot of these researches in the course of your work, and even mentoring. I know that we have a lot of young doctors, doctors that are in training that go from Nigeria to Uganda to learn that palliative care system.

Most admirable and must commend you for the leadership position that you have taken in this. So, my next question to you is that, having been involved in these numerous researches that spans the HIV space, cancer, and of course, palliative care, and you’ve contributed to several publications and books in these fields, how do you ensure, you touched on the implementation a little bit, but let us know how we can learn from your experience, ensuring that the findings from these studies translates into practical improvement in the patient’s care.

You know, at the patient level, how can we see that work that you’re doing improve the lives of patients living with cancer?

Emmanuel Luyirika: Okay, thank you very much. As you know, to be able to pull off any program, it takes a number of players. The first group that is very important are the policy makers in government, and especially the Minister of Health, Minister of Finance and Parliament.

And so, we use a multi-pronged approach. Our interaction with ministers, we interact with African ministers of health every three years with their delegations. And we discuss with them issues in palliative care and look at the challenges they have, look at the resources they have, examples they can learn from across continents, I mean, from across countries.

And so, we do that deliberately every three years, so that the ministers have an idea. And then we also engage with the providers through the International African Palliative Care Conference, where people come and share their achievements, but also their challenges. And then we are able to then create an opportunity where those who need training, get training, those who need small grants to improve, we get them small grants.

We get involved in supporting individual hospitals and service providers as they develop their services. For example, to that effect, we’ve worked out a costed essential palliative care package for integration into universal health coverage, which we’ve then given to countries so that they can then implement that. We’ve also given them tools like the palliative care standards, so that facilities can measure and see where they stand in terms of the acceptable standards in terms of delivery.

So, our engagement at the health work level, at the health training level, at policy maker level, brings all these together to deliver service. The other thing that we do is to help people move from one country to go and see a practice in another. For example, when we were implementing a project in Liberia, we had our colleagues from Nigeria, led by Professor Olatan, visit and support people in Gambia and Liberia on how they can implement their services better.

Then we had those from Togo visit Malawi to see how Malawi is doing it. And then we had the team from Eswatini or Swaziland move to VITS hospice in South Africa to see how that is being done. And then we had the team from DRC and Rwanda and Kenya come to Uganda to see real service delivery.

So, peer-to-peer learning has also been a tool that has now caused other people to go back and do what they should do. And when the visits are done, we ensure that we have multidisciplinary sites. For example, when they come to Uganda, they will visit the Uganda Cancer Institute, see their patient navigation system and how they deliver services.

They will go to the Morphine Reconstitution Factory at Hospice Africa, Uganda. They go to National Med to see morphine and other controlled medicines. They will visit a hospice and see how patients get services in the home.
So, it’s a number of things that we do to get to where we want to be.

Zainab Shinkafi-Bagudu: To get the implementation. And indeed, some of it is translating and we can see the effects. You mentioned morphine when you were talking there.
And of course, funding. Funding is an issue. And the fact that you have to give some small grants to organizations and researchers.

And even to access the palliative care, the patients have a lot of issues with funding. So, one of the things that was advocated for by our team in Nigeria, who we know quite well, is a palliative care fund, which was started. And I found out that they give the sum of 50 Naira for 50,000 Naira per patient.

And a vial of morphine costs 200,000 Naira. So, it’s supportive, but it’s still not going to be able to get them the cost. I don’t think they give the patients the fund directly.

It goes into an e-wallet in the hospital, but it’s still not enough. How can we help with this funding issue? It’s funding for treatment.
It’s funding for diagnosis. It’s funding for palliative care in LMICs. It’s funding for research and even becoming a doctor, a nurse, healthcare professionals.
And we’re seeing we’re losing all our healthcare professionals to higher income countries now. So, this is a bit of a maybe political question, but what do we do about this access in Africa?

Emmanuel Luyirika:  Okay. Let me start with the morphine itself. The, for morphine, the model that works is to, because morphine is cheap.
If you’re not buying it from a private company, it’s very cheap. A bottle of 500 mils costs about three US dollars. I don’t know how much that would be in Naira.

Zainab Shinkafi-Bagudu: Six thousand.

Emmanuel Luyirika: Yeah, that would be. So, a bottle once produced using the model we have in Uganda is three dollars.

We need to integrate it into existing cancer care so that you have the same system that delivers all the rest of the cancer care, delivering palliative care, and then linking it with the system that reaches the patient’s home. For example, in some of the countries, they have a strong PHC program that is paid for by government. The same PHC program will deliver palliative care, will deliver the morphine and other medicines.

If you take the example of Botswana, Botswana, they even have a defined package for a patient who needs palliative care in the household, which includes, of course, your usual medicines. It includes things like diapers, stomach bags, and even a food basket. So, we need to encourage governments to look at practical models that can be delivered, and that also goes with other investments.

You’ve invested in a nice cancer hospital. If it’s hospital-based, then you know where all your patients are coming from, you know where they are, you know what stages they are, and then you are able to link them to some of these services. So, it goes with using the numbers and the infrastructure that you have to deliver the service you have, but we know that governments are also limited by resources.

So, governments need to work with the non-government sector, with the faith-based sector, to reach the same goal as well. If you take the example of Botswana, where they don’t have a hospice and there is a hospice, then government will contribute some money to that hospice to deliver the service where government is not able to reach. The same happens in Uganda as well.

They give some money to some of the hospices, either in cash or some items in kind, so that the non-government hospices can support patients where they provide those services. So, it is a mud-pronged approach again to funding. I heard you talk about the palliative care fund.

In the last training we had for hospices in Africa, which took seven months, we developed a tool that can help national palliative care associations and cancer organizations to be able to develop a national palliative care fund, which they can break up into various levels, service delivery, research, education, and then the admin component, so that they can also tap some money from the private sector to complement that which government is putting in the pool.