In resource poor areas, the blending of supportive care with hospice/palliative care is frequently linked to the development of previously established services, particularly home based care. Where opioids are unavailable, however, the definition of palliative care can be problematic. We have taken the view that where a service is in the process of development from (largely) physical care to a broader form of holistic care that approximates to the WHO definition, it should be included in the review.

In Tanzania, Palliative care is given by four organisations: Selian Hospital, Muheza Hospice Care, PASADA, and Ocean Road Cancer Institute (Table 1).

Table 1 Palliative care provision in Tanzania, 2004

In Tanzania the faith-based organisations, particularly the church-related hospitals, provide 50 % of the health care in the country.² Plans are in place to extend palliative care coverage into the Christian hospitals (around 82) throughout Tanzania. The Evangelical Lutheran Church, which has its national headquarters in Arusha, is introducing palliative care into its 20 Lutheran hospitals. Healthcare is traditionally family and home-based due to the low doctor to population ratio.

Selian Lutheran Hospital

This 100-bed hospital in Arusha services 55-60,000 patients annually.³ The hospice programme is a response to the burden of AIDS in the area and consists of a small team that provides home-based care. The service is administered by the hospital. The team has trained 120 volunteers that visit approximately 300 patients on a weekly basis to provide ongoing care after discharge from hospital. This includes spiritual care and symptom relief.

Muheza Hospice Care

This is a rural community-based palliative care programme based at Teule District Hospital. This district hospital is partly run by the Anglican United Society for the Propagation of the Gospel, and partly by the Tanzanian Government. The hospice service comprises a 5 bedded palliative care ward within the hospital, a separate hospice building administering home based care using village health workers and volunteers, a once weekly day hospice, and a drop in centre open 5 days a week for medical examinations, voluntary counselling and testing (VCT) and counselling. A weekly sexually transmitted illnesses (STI) clinic was opened in April 2004 and attended to 225 patients by the end of 2004. Records show the following activity in 2004 (Table 2):⁴

Table 2 Muheza Hospice Care attendances, 2004

During 2004, the home care team made 253 visits to a total of 98 patients.⁵

Activity from 2002 is shown in Table 3.

Table 3 Muheza Hospice Care activity and patient diagnoses, 2002-2004

Source: Muheza Hospice Care Annual Report, 2004

A monthly ‘Kids Club’ provides support for around 40 HIV affected children. Angela Kaiza explains:

The aim of the club is to gather around all the children who are sick so that they have time together, so that they may enjoy that we may give them some food, we may talk with them, and we see, we try to see also their underlying problems, emotional problems, social problems which are facing them.⁶

This is achieved in a programme incorporating story telling, drawing, games, HIV education and hygiene.

Most palliative care activities operate from a separate hospice building known as The Diana Centre, at the entrance to the hospital. The centre is intended to be both an outpatients unit and a social venue. From an initial 12 patients the numbers have grown dramatically, partly because food is provided. Karilyn Collins explains:

We have a lot of starving patients who see day hospice as a day when they can get food, but they also see it as a day when they have to see the doctor…⁷

The hospice also attends to about 20-30 patients on other wards in the hospital. After discharge patients are referred to the hospice for regular monitoring and home visits. Trained community volunteers and village health workers continue to visit the patients once they are home.

A well-established antiretroviral programme provides free treatments for staff and patients. During 2004, 161 patients, 21 staff and 32 children received Antiretroviral therapy.⁸

Pastoral Activities and Services for People with AIDS Dar es Salaam Archdiocese (PASADA), Dar es Salaam

This home-based urban outreach programme specifically cares for patients with HIV and AIDS. PASADA collaborates with the Diocesan Community Health Education Programme (DCHEP) whose community volunteers are trained in basic nursing and counselling skills so as to be able to identify those people in need of care within their communities. The volunteers remain in contact with about 600 families under supervision from the PASADA team. The service by late 2004 was comprehensive: medical assistance and routine treatment of opportunistic infections; laboratory services; a pharmacy; counselling; home-based palliative care; support to orphans and vulnerable children; a programme for Prevention of Mother to Child Transmission (PMTCT); tuberculosis diagnosis and treatment; training. The Orphans Department provides counselling for children whose parents have died. They also lobby the legal system to protect these children who are vulnerable to abuse, and have noticed an increase in the number of orphans who are prepared to talk of the sexual abuse they have suffered. By November 2004 there were 12000 registered HIV positive clients, including 600 children.

Ocean Road Cancer Institute (ORCI)

This is the only dedicated cancer hospital in Tanzania. Palliative care services are in their infancy but with the support of the Hospital Director Twalib Ngoma, a palliative care unit has developed within the hospital. Its main function is that of a hospital support team. The unit operates an outpatient clinic as well as a hospital support team. Ward rounds and regular consultation with hospital medical staff ensure that patients are referred to the palliative care unit when appropriate. Patients are assessed each morning in the palliative care team office. Inpatients are visited three times a week. The team additionally accompanies members of staff on their ward rounds to be able to identify patients who could benefit from their input. The team links with already established home care providers in the city to provide continuity upon discharge. Due to financial constraints there are no immediate plans to develop hospital home based care. This is identified by the palliative care team as a gap in the provision of care. Another gap is follow up of patients who live outside of Dar es Salaam. The existing home based care providers are both non-governmental organisations (NGOs) and government district hospital teams. They have limited training in providing support for the dying at home, and are not trained in pain control. While minimal support is therefore available in Dar es Salaam, this is entirely lacking when patients return to their rural homes. Mary Haule explains some of the problems:

We have cancer patients who have AIDS also, but we know there are a lot of AIDS patient at home who are, have not cancer but they are suffering from severe pain, but this pain they are not attended to, but there is, they have no skill, the home care team, especial those by the government, they have no training in pain control…sometimes they can’t appreciate that this patient will need some strong pain medication because there is still fear in many of these people that morphine is a dangerous drug, is a lethal drug.⁹

The palliative care team relies on family members to inform them of the patient’s progress and collect medication. Only those patients who have access to home based care support receive care at the end of life. Notification of a patient’s death depends on the family’s ability to come to the hospital.