Special Report: Malawi

2022; Volume 23, Number 1, January

Advocacy Succeeds in Improving Morphine Supply
and Changing Pharmacists’ Attitudes in Malawi

By Lameck Thambo, Executive Director
Palliative Care Association of Malawi

The Palliative Care Association of Malawi (PACAM) is a vibrant nonprofit organization whose mission is to support the development of affordable and culturally acceptable palliative care in Malawi. PACAM’s vision is for a country where all people with serious illness are free of pain and distress.

Advocating for availability and accessibility of essential palliative care medicines, mainly morphine, is a key role of the association. From its inception in 2005, PACAM pressed the government to procure morphine and dispense it to patients free of charge. In 2014 we celebrated the government’s decision to respect patients’ right to be pain-free by making morphine available throughout public health facilities.

Availability increased, but stock-outs occurred
Training for pharmacists on the importance of morphine in palliative care. Photos supplied by PACAM. Used with permission.

A national report on palliative care by the Ministry of Health, spanning July 2020 to June 2021, indicated a stable increase in morphine availability and patient access. The trend was particularly evident in the use of morphine liquid and tablets. This is an indicator of good progress in opioid availability and pain management in Malawi.

However, findings by the STEP UP project (funded by True Colours Trust), which monitored national palliative care services during the same time period, observed that some health facilities experienced morphine stock-outs that lasted days and, in some cases, months. For this reason, PACAM called for a drug task force meeting on August 20, 2021, to understand what the problems were and to be updated by procurement agents on both liquid and powder morphine stocks.

Pharmacists needed information
& critiqued order requirement

The meeting was attended by representatives from the country’s two procurement agents, Central Medical Stores Trust (CMST) and the HIV/AIDS unit, as well as representatives from the Ministry of Health Pharmaceuticals Department, the Pharmacy Medicine Regulatory Authority, and a sampling of pharmacists from district hospitals. CMST reported that it had 40 pounds (18.2 kg) of morphine powder available and procurement of 66 pounds (30 kg) was underway. As for morphine stock-outs, it was reported that hospital pharmacists did not prioritize morphine orders and, as a result, requests to CMST were delayed. Pharmacists complained that because morphine is not included on the Ministry of Health’s online list of essential medicines, it must be ordered separately and manually, which keeps it off regular orders. They also acknowledged that they don’t have enough information about the importance of morphine for palliative care.

A meeting of the Palliative Care National Drug Taskforce.
Two-day training was effective

In response to pharmacists’ acknowledgement of knowledge gaps, PACAM conducted a two-day training session on September 15 and 16 at the Vintage Conference Centre in Mponera. It was attended by 28 pharmacists: one from every district hospital; plus one each from the Ministry of Health Pharmaceuticals Department, Central Medical Stores Trust, and the Pharmacy Medicine and Regulatory Authority.

Pharmacists had this to say:

“I confess that I caused pain in many patients when morphine was not available at my pharmacy because of my negligence in ordering, not realizing that morphine is an important medicine for patients with severe pain.” —A senior pharmacist

“This training is an eye opener and paramount for us pharmacists, I have been hearing about palliative care and have been denying to join the palliative care team... I thought was a waste of time, but now I will be an active advocate.” —A pharmacist

“[I]f all pharmacists in Malawi including our bosses would attend this training, the issue of morphine-related challenges, such as stock-outs in the country, would be past history.” —A pharmacist from the CMST region

“I was very reluctant and uncomfortable to issue a one-month supply of morphine, a controlled medicine, to patients for fear of abuse and addiction—but now I understand why we should, and its importance for patients and us as well.” —A pharmacist who had been opposed to fulfilling monthly prescriptions for morphine

A group photo of pharmacists who took the two-day training course.

To learn more about the Palliative Care Association of Malawi (PACAM) visit the IAHPC Global Directory of Palliative Care Institutions and Organizations.

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