ISTORIA DE L'ARAGONÉS: O sieglo XIX (2)

The political factors that were described in the sixteen included articles as hindering the adequate provision of PC include limited availability/accessibility to opioids, funding and policy for PC. Whilst three empirical research studies reported on the

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unavailability of and/or limited accessibility to opioids in countries such as Malawi, Nigeria, Kenya, Namibia, Cote d’ Ivoire (Tapsfiedl and Bates, 2011; van Gurp et al., 2014; Rhee et al., 2018), the survey, which involved 75% of countries in the African region, found that 14% of them had oral morphine available in most of their pharmacies (Sharkey et al., 2018). The likely factors explaining the limited availability/accessibility to opioids included opiophobia, lack of knowledge, inadequate trained manpower for opioid prescription, lack of nurse-prescribing laws/policy and lack of infrastructure to store and distribute them (Clark et al., 2007; Hannon et al., 2016; Rhee et al., 2018; Fraser et al., 2017). This limited availability/accessibility to opioids contributed to unmet pain needs for the terminally ill and dying patients (Uwimana and Struthers, 2007; Tapsfiedl and Bates, 2011; Kolawole et al., 2013; Harding et al., 2011; Harding et al., 2014; Downing et al., 2014; Olaitan et al., 2016). Although, there is limited availability/accessibility of opioids in most of the African countries, countries such as Uganda, Kenya, Malawi, Zambia, Tanzania, Mongolia, Ethiopia, and Zimbabwe were reportedly making great progress to improve their availability and accessibility (Lynch et al., 2013; Hannon et al., 2016; Fraser et al., 2017). Only South Africa belonged to the countries in which opioids analgesic were available but access was restricted by bureaucratic forces (EIU, 2015).

Another political factor hindering PC related to funding and policies. The multi-method review that mapped the level of PC development in 2007 showed that 26 out of 47 African countries with a known PC activity hugely depend on external funding for PC (Clark et al., 2007; Wright et al., 2008). The similar review conducted four years later showed there was no significant improvement in the commitment by the government for funding PC because majority of African countries were still reliant on the external financial aid to fund PC except Cote D’ Ivoire that has established multiple source of funding for PC (Lynch et al., 2013). Poor funding of PC has continued to exist in most of the African countries as shown in the 2015 quality of death index and other reviews (EIU, 2015) and as also acknowledged in the scoping and narrative reviews by Rhee et

al., (2017) and Hannon et al., (2016). The availability of public funding for PC which is

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other five categories in the QOD index showed that few African countries such as Uganda, Ghana and Kenya had government funding for PC though funds were difficult to access (EIU, 2015). Nigeria ranked last in this category among other 80 countries assessed in this index, though with countries such Malawi, Tanzania and Egypt also had total absence of government subsidies for individuals accessing PC, unlike other countries (Botswana, Ethiopia, Morocco, South Africa, Zambia, Zimbabwe) that had a limited number of government subsidies (EIU, 2015). This could indicate that Nigeria was one of the African countries where the government seemed to be generally reluctant in the internal funding of PC.

Furthermore, the healthcare professionals that participated in the empirical study conducted in Nigeria reiterated lack of government funding for PC (van Gurp et al., 2015). Likewise, the in-country experts in PC from Ghana, Kenya, Mozambique, Nambia and South Africa was said to have unanimously reported that their countries have continued to depend largely on external funding for PC (Rhee et al., 2018). For instance, they reported that withdrawal of external funding for HIV/AIDS in South Africa caused closure of many hospices (Rhee et al., 2018). Concordant with previous findings, the survey about the countries’ capacities for the prevention and control of noncommunicable diseases that included questions on a number of PC development metrics among the WHO member states reported that a small proportion of countries in Africa region had funding available for PC (Sharkey et al., 2018). This could imply that funding of PC could still be one of the barriers impacting on PC development in African countries, however these studies did not capture the underlying reasons for this, suggesting a need for a more comprehensive and in-depth study.

Lack and/or inadequate policy implementation for PC was revealed as a barrier to provision of optimal PC in the empirical research conducted in Rwanda and Nigeria (Uwimana and Struthers, 2007; van Gurp et al., 2015). These two studies did not provide explanations as to why there was lack/inadequate policy for PC. The use of survey by Uwimana and Struthers, (2007) may have accounted for this, though the latter study used qualitative approach, yet the complexities underlying PC policy was

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uncovered. This suggests limited knowledge about PC policy in these two countries. However, other African countries appear to be in a similar situation because only 54% among 35 countries in African region that participated in the survey conducted by Sharkey et al. (2018) reported having a National policy for non-communicable diseases including an operational policy for PC. Other previous reviews also showed that most of the African countries lacked policies for PC (Clark et al., 2007; Wright et al., 2008; Lynch et al., 2013; Hannon et al., 2016). However, countries such as Uganda, Kenya, Zimbabwe; South Africa (Clark et al., 2007; Wright et al., 2008; Lynch et al., 2013) Cote D’Ivoire, Rwanda, Tanzania (Hannon et al., 2016; Rhee et al., 2017) were reported to either have integrated PC into healthcare policy or are gaining wider PC policy recognition.