Side event: Increasing access to controlled medicines for medical purposes: focus on Africa

Organized by the Governments of Belgium, France, Kenya and Nigeria, the International Association for Hospice and Palliative Care, the African Palliative Care Association, the International Youth Association for Development and Palliafamilli, the Union for International Cancer Control, the International Narcotics Control Board, the United Nations Office on Drugs and Crime Drug Prevention and Health Branch, and the Vienna NGO Committee on Drugs.

Viroj Sumyai, INCB president: Increasing access had been a focus for INCB for several years. The data available to INCB shows a decline of use of opioids in Sub-Saharan Africa overall over the past ten years, while in some subregions there was an increase, notably in some East African countries. The situation is most worrisome in West and Central Africa. He pointed out that mental health issues co-occurr with cancer treatment such as anxiety and insomnia. There is need for training medical personnel and to have medicines for this need to be available, e.g. Diazepam (Valium) which is one of the most affordable. However, in Sub-Saharan Africa only Kenya manufactures Diazepam and all other countries would have to rely on import. But over a third of countries did not report any import at all. Only 12 countries reported consumption. This needs to be part of the national health care strategy. The INCB president called for better reporting from countries. He pointed to the UNGASS outcome document and INCB call for countries to improve their national systems and to make sure essential medicines are available and affordable. The INCB has asked to have responses to how countries are advancing on this which will feed into 2018 INCB report. He thanked Belgium, the US and France who support these INCB efforts.

Ambassador Michael A.O. Oyugi, Kenya and CND Vice-Chair: In Kenya the legal framework is the act of parliament “Narcotic and psychotropic substances act”. The national 2016 essential medicines list included controlled substances. They are available in pain management centres. But nevertheless coverage is low. He identified several barriers: Training of medical personnel is lacking; inadequate information of medical personnel and patients; high cost (opioids are used largely in private institutions  and not state hospitals and paid out of pocket); inefficient supply chain system. He then shared recommendations to increase access in his country: to review legal framework in light of UNGASS outcome document, to increase capacity building etc.

Ambassador Jean-Louis Falconi, France: France is working with African countries to improve access. There is great unmet demand. France has advocated for increased access internationally for a long time, including a French-sponsored resolution at WHO in 2014. There is a need for capacity building on prescription, administration and also patient information.

Elizabeth Mattfeld, UNODC Drug Prevention and Health Branch: Did not want to take up much time. She referred data from the Pain and Policy Study Group at Wisconsin University. This data shows that for Sub-Saharan Francophone Africa the Morphine Equivalence (ME), adjusted for population is 0.32. The highest consumption is in Mauritius with 4.75. To compate the ME for the US is 475, for Austria 500, and for Canada 675.

Emmanuel Luyirika, Executive Director, African Palliative Care Association:  They offer technical support to CSOs and NGOs and ministries of health. The countries with the highest availability of morphine in Africa are: Tunisia 64%, South Africa 49%, Namibia 28%, Botswana 25%, Mauritius 22%, Cape Verde 15%, Ghana 12% and Uganda 11%. Less than 20% of countries have palliative care policies (South Africa, Rwanda, Mozambique, Tanzania, Botswana, Malawi, Zimbawe, Swaziland, Tanzania). The only African countries with active palliative care training programs at diploma and degree level are South Africa, Uganda, Kenya, Malawi and Tanzania. There are countries were 0% of need is met, such as Central African Republic, Comoros, Djibouti, Equatorial Guinea, Gambia, Burundi and others. The main barriers are: overemphasis on control rather than ensuring accessibility, complicated procurement and supply chain issues, lack of prescribers at the point majority of patients need it; the cost of morphine for patients. Francophone, lusophone and Western African countries are especially not providing access. There is a need to focus on low cost package established in 2017 Lancet report.

Anselme Kananga, Palliafamilli, DRC: They formed an association 10 years ago to attend palliative care patients in DRC. They work on advocacy – which led to national guidelines published in 2017; sensibilization (of medical personnel) including training and setting up a specialized library; and implementation including 2 mobile teams.

Representative from the National Drug Law Enforcement Agency of Nigeria: Nigeria consumes only about 0.1% of narcotic analgesics needed for AIDS patients only. There is a project with the American Cancer Society since 2012 on “Treat the Pain” which includes pilot “pain free hospitals”. Nigeria launched 4 guidelines: National Minimum Standards for Drug Dependence Treatment in Nigeria, 2015; National Policy for Controlled Medicines and its Implementation Strategies, 2017; National Guidelines on Estimation of Psychotropic Substances and Precursors, 2017; and National Guidelines for Quantification of Narcotic Medicines, 2017. They will be available online within about a month. Minimum treatment standards were necessary as there were many unregulated private providers. Nigeria did its first national estimation of need for controlled medicines in 2017 so they now have a realistic picture of the needs and need to improve access. The next steps are to develop regulations and guidelines (which translate the policies); decentralize the narcotics warehouses (currently only one in Lagos, others have to come there and carry the medicines back to their locations); local manufacture of narcotics; revise curriculum of medical, pharmacy and nursing school on rational use of controlled medicines – need to improve knowledge; and review of inventory and record keeping tools (against diversion).

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