The following organisations feature prominently in Tanzania:

African Palliative Care Association (APCA)

The African Palliative Care Association was formally inaugurated at a conference in Arusha in June 2004. The concept was born in 2002 in Cape Town, South Africa at a meeting to look at issues of palliative care education in Africa. The desire to link knowledge, resources and networks throughout Africa formed the motivation to form the association.Steering committee members were drawn from: Kenya (Zipporah-Merdin Ali), South Africa ( Kath Defilippi), Tanzania (Mark Jacobson) Uganda ( Anne Merriman) and Zimbabwe (Sambulo Mkwananzi).¹⁵ In summary, APCA aims to:

• promote study, knowledge, training and research in palliative care
• foster networks and links at all levels of palliative care
• address ethical issues
• establish an international communication network
• sponsor publications
• disseminate achievements
• promote access to resources

Objectives include:

• promotion of standards
• advocating for palliative care at governmental level
• securing the availability of drugs
• encouraging the development of national associations within Africa
• promotion of training programmes
• devising standard guidelines
• advocacy

President’s Emergency Plan for AIDS Relief (PEPFAR)

During his state of the Union address in 2003, President Bush announced his PEPFAR initiative; this groundbreaking intervention encompasses HIV/AIDS activities in more than 75 countries and focuses on 15 countries worldwide – of which Tanzania is one of 12 in Africa – to develop integrated care and treatment programmes (Table 3). Over the next 5 years, PEPFAR is donating a total of US $15billion, of which 15% is earmarked funding for palliative care. This has dramatically changed the palliative care landscape in Africa, as bids for new initiatives are attracting the funding for implementation. Four main areas are targeted:

• prevention of HIV transmission
• treatment of AIDS and associated conditions
• palliative care for HIV infected individuals
• care for AIDS orphans and other vulnerable children

Tanzanian Palliative Care Association:

A national association was formed in Arusha in June 2004 to provide a voice for palliative care in Tanzania. About 50 care providers in Tanzania were represented, mainly from the Lutheran hospitals and home based care organisations.

The Diana, Princess of Wales Memorial Fund (The Diana Fund)¹⁶

The Diana Fund has formed the view that palliative care plays a vital role in the management of life-limiting illness. In particular, palliative care is ideally suited to home based care; it makes use of affordable drugs and it empowers the family to care for their members more effectively.

In 2001, the Diana Fund launched a palliative care initiative which focused on nine countries in sub-Saharan Africa ( Ethiopia, Kenya, Malawi, Rwanda, South Africa, Tanzania, Uganda, Zambia and Zimbabwe) and committed an initial £5 million over 5 years. The Fund does not implement palliative care programmes; rather, it supports locally-based partners who are already implementing programmes or who wish to incorporate palliative care into existing home based care services.

The Diana Fund has supported palliative care development in Tanzania through the award of grants, including:

• a 1 year project to set up palliative care training and referral facilities for Muheza district at Teule Hospital, and to establish home based care in the area: £41,040 (2002)
• PASADA – a 3 year grant to move from clinic based to community based health services and to strengthen the palliative care component of the work: £150,000 (2002)

The World Health Organisation (WHO)¹⁷

The WHO is currently involved in a community health approach to palliative care for HIV/AIDS and cancer patients in Africa. This joint project - involving the five countries of Botswana, Ethiopia, Tanzania, Uganda and Zimbabwe - seeks to improve the quality of life of HIV/AIDS and cancer patients in Sub-Saharan Africa by developing comprehensive palliative care programmes with a community health approach. The project contains four major elements: team building, situation analysis, needs assessment and action plans (Table 5).

Table 5 Countries of Africa involved in PEPFAR, the Diana, Princess of Wales Memorial Fund and WHO projects

In a progress report published in 2002, the executive summary drew attention to some of the challenges faced by these countries:

All five countries have health systems which combine modern medicine and traditional medicine. Access to modern medicine is limited and a high percentage of the population will never see a doctor in their lives. The health systems are organized according to different levels of care and great emphasis is placed on primary health care (PHC). In all of the countries, there is serious shortage of human resources and health care providers and hospitals are overloaded by the HIV epidemic. Some of them report greater than 50% of hospital beds occupied by HIV/AIDS patients. Limitations of infrastructure, equipment and supplies are the norm. Home based care is viewed as the key element to respond to the increasing needs in this scenario of very limited health infrastructure and resources. Some countries have already developed strong home based care networks in coordination with the PHC system to respond to the HIV epidemic. Palliative care, as part of the continuum of care of HIV/AIDS, cancer and other chronic conditions can relatively easily be integrated into this existing network.¹⁸

The final report identifies some of the challenges:

Information obtained from a wide range of community resource people clearly identified the need for palliative care programmes, dealing with the gaps in the provision of care to the terminally ill. However, financial constraints, a shortage of trained staff, a lack of openness from such patients, and stigma were major constraints to the effective delivery of such services in a home setting. Further investigation is needed to establish clear programme components and financial requirements for terminally ill patients in the African setting. Stigma is a significant problem that the society needs to solve, as most members of the community can’t identify with the patient or caregiver and are unfamiliar with the needs of the terminally ill.¹⁹

The William Jefferson Clinton Foundation ( Clinton Foundation)

The Clinton Foundation of New York City has undertaken to assist four African countries ( Mozambique, Rwanda, South Africa and Tanzania) and several Caribbean countries develop plans to improve HIV/AIDS care and treatment. Several characteristics guide the Foundation’s work:

• The Foundation considers the HIV/AIDS crisis an international public health emergency, and believes speed is of the essence both in making plans and in implementing them
• The Foundation practices a comprehensive approach, supporting programmes that reach all corners of its partner countries and that provide comprehensive care and treatment
• The Foundation emphasises antiretroviral treatment of HIV+ individuals both as a proven method to extend and improve life and as a necessary component of an effective prevention strategy
• Since HIV/AIDS is a country-wide, long term intractable challenge, the Foundation believes national governments must shoulder the responsibility for both planning and implementation of comprehensive programmes, and thus works primarily through government agencies in offering its assistance
• Finally, the Foundation believes an important part of its work should be to strengthen the overall healthcare infrastructure of its partner countries for the long term.²⁰

Specifically the Clinton Foundation has identified an HIV/AIDS care and treatment plan for Tanzania for 2003-2008:

Goal one: To provide quality, continuing care and treatment to as many HIV+ residents of the United Republic of Tanzania as possible, building on the careful planning already completed by the Ministry of Health and the Tanzania Commission for AIDS.

Goal two: To contribute to strengthening the healthcare structure of Tanzania, through expansion of healthcare personnel, facilities and equipment and comprehensive training in the care and treatment of people living with HIV/AIDS (PLWHA).

Goal three: To foster information, education and communication efforts focused on increasing public understanding of care and treatment alternatives, reducing the stigma associated with HIV/AIDS, and supporting ongoing prevention campaigns.

Goal four: To contribute in strengthening social support for care and treatment of PLWHA in Tanzania, through home-based care, local support groups, and treatment partners.