Go-ahead for palliative care nurses in Zimbabwe to prescribe morphine for pain management

The good news is that a new Statutory Instrument (SI) permitting palliative care-trained nurses registered with the Nurses Council of Zimbabwe to administer, prescribe and be in possession of morphine for palliative care was finally gazetted.

This breakthrough came after more than two years of relentless lobbying. The road leading to this accomplishment had neither been simple nor straightforward. It began during a routine Hospice and Palliative Care Association of Zimbabwe (HOSPAZ) membership meeting in early 2016, where a senior World Health Organisation (WHO) official presented on the World Health Assembly (WHA) Resolution on Palliative Care (2014), in which she highlighted and unpacked the key aspects.

After the presentation participants were shown “Little Stars” — a series of short paediatric palliative care movies, in a bid to show what palliative care in a variety of settings entailed. What we observed was that unlike most of our palliative care patients, the children shown in the movie seemed to experience little or no pain at all and their families were well prepared.

It was at that point that a Palliative Care Advocacy Group comprised of palliative care individuals and organisations led by HOSPAZ was born. The group immediately came up with a list of palliative care issues that we needed to address, taking advantage of some “low-hanging fruit”. These included the National Palliative Care Policy (2014), the National Palliative Care Curriculum (2014), the National Palliative Care Training Manual (2014), and the National Health Strategy 2016-2020, which included palliative care.

The umbrella body’s amicable and professional working relationship with WHO, as well as the Ministry of Health and Child Care (MOHCC), with whom they had an MOU, was another low-hanging fruit to be exploited.

Chief among the list of priority problems we identified was the fact that palliative care practitioners felt frustrated at having witnessed countless palliative care patients dying in pain, even though the use of morphine for pain treatment was legal in Zimbabwe.

The major drawback was a law, the Dangerous Drug Act (DDA), which limited prescription of morphine to medical doctors exclusively, when there is such a low doctor to patient ratio — just like elsewhere in Africa. Bearing this out, statistics from a three-country national morphine survey conducted in 2015, showed the underutilisation of morphine in Zimbabwe, which used only 10.1kg of the estimated 177kg needed, based on the numbers of those experiencing severe pain at the end of their life in Zimbabwe.

It was agreed that this was unacceptable and needed to be addressed promptly. With greater involvement of MOHCC’s Non-Communicable Diseases Unit, HOSPAZ took advantage of the theme for the 2016 World Hospice and Palliative Care Day (WHPCD), “Living and Dying in Pain, It Doesn’t Have to Happen” to further raise awareness about the need to manage pain in palliative care.

After a series of meetings in 2016, a presentation was made to MOHCC Permanent Secretary and the Top Management Team about the WHA Resolution and its key tenets. Targeting the policy and decision-makers was needed for their buy-in, and also because the national Palliative Care Situational Analysis (2012) had revealed knowledge gaps about palliative care among both members of the public and health professionals (leadership included).

During the first quarter of 2017, HOSPAZ, on behalf of the palliative care advocacy group approached the MOHCC Director of Nursing as well as the Director Epidemiology and Disease Control for guidance on how best to go about seeking permission for the palliative care-trained nurses to prescribe morphine for patients under palliative care. Then, further consultations took place with the nurses’ regulatory body — the Nurses Council of Zimbabwe (NCZ) which provided advice in support.

When we finally met him, the permanent secretary for health requested HOSPAZ to come up with a written justification for the request. This was expeditiously done, citing the example of other nations such as Uganda, as well as the example of Zimbabwe nurse-midwives who because of shortages of obstetricians, are authorised to prescribe, (and are already competently prescribing) yet another opioid — pethidine and its derivatives. In this instance, the MOHCC had introduced “task sharing” to compensate for shortages of health professionals and was working towards having nurses to initiate Anti-Retroviral Therapy.

So, following several internal consultations with relevant directorates, approval was given in a letter to HOSPAZ in July 2017 from the permanent secretary for health and child welfare. From that point on, assuming the process was complete, HOSPAZ was asked by stakeholders to spearhead the development of relevant guidelines for palliative care trained nurses.

However, in early 2018, as MOHCC, HOSPAZ, and Island Hospice embarked on the integration of palliative care into the national health system, it emerged from members of the Palliative Care Essential Medicines and Equipment taskforce that the process was far from over. HOSPAZ was advised to engage the Medicines Control Authority of Zimbabwe (MCAZ), the regulatory arm for pharmaceuticals and other medical equipment, requesting the necessary amendment of a relevant statutory instrument using the permanent secretary’s approval letter.

When this happened, several clarifications were then sought by MCAZ in order to fully understand the arrangements and parameters of operation, before their legal team could start working on the amendment process.  Eventually, when all due diligence had been done, statutory amendments were made to the Dangerous Drug Act, and submitted to the minister for health and child welfare and attorney-general. This was how we gave birth to Statutory Instrument 232 of 2019, gazetted on 8 November 2019.

Some might wonder why the statutory instrument is great news for palliative care in Zimbabwe. It is because pain has a profound impact on the quality of life and can have physical, psychological, spiritual and social consequences.

It can lead to reduced mobility and a consequent loss of strength, compromise the immune system and interfere with a person’s ability to eat, concentrate, sleep, or interact with others. Now, with palliative care-trained nurses being able to prescribe morphine for palliative care pain management, quality of care for the patients is guaranteed.

Advocacy works! What more can we say! MC

 Julieth Musengi is a programme officer and Eunice Garanganga the director of HOSPAZ.