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Botswana Ministry of Health Benchmarking Visit to Uganda on local reconstitution of oral liquid morphine to improve access to pain management services

Author: : Fatia Kiyange and Wedzerai Chiyoka of the African Palliative Care Association and Ms Penny Makruetsa of the Botswana Ministry of Health
21 May 2018

In its efforts towards the implementation of the May 2014 World Health Assembly resolution on strengthening palliative care as a component of comprehensive care throughout the life course, the Government of Botswana launched its National Hospice and Palliative Care Guideline in October 2015.

One of the stated goals in this policy is to ensure the consistent availability and accessibility of essential palliative care medicines for those who need them, at the time they need them.

Some of the specific objectives of the government include;

  1. Strengthening the supply chain mechanism for opioids and other pain medicines in Botswana and
  2. Improving capacity for effective use of opioids and other pain medicines in pain control.

Botswana is currently importing ready-to-use morphine syrup which is expensive, compared to locally reconstituted liquid oral morphine, a model which has been used in Uganda over some years. As a policy initiative, the Government of Botswana through its Ministry of Health, set out to explore and consider a mechanism for local reconstitution of powdered morphine into an oral liquid solution to reduce the costs of importing ready-to-use morphine.

The African Palliative Care Association (APCA), with funding support from the American Cancer Society’s Treat the Pain Program has been providing technical support to the Government of Botswana through the Ministry of Health and the Central Medical Stores towards this initiative. The Government has now procured its first supply of morphine powder (5Kgs) in preparation for initiation of the local production of oral liquid morphine. Oral liquid morphine has since been added to the Essential Drugs List in the country. A technical working group has also been instituted, coordinated by a Pharmacist, to oversee the processes for local morphine production. The Ministry of Health is currently having discussions and negotiations with the Institute of Health Sciences in Gaborone, Botswana for the provision of possible space for the production of oral liquid morphine. Two major referral hospitals have also been identified for the pilot production, with plans to roll out to all district hospitals. This follows their implementation of the Pain Free Hospital Initiative which has seen most of the health care workers in these hospitals trained on pain management, leading to higher demand for pain medications

In March 2018, the Ministry of Health Botswana sent a 6-member delegation on a benchmarking mission to Uganda, where local reconstitution of morphine has been done for some time. The visit, which was coordinated by APCA served as a fact-finding and learning mission.  The visiting team in Uganda included: Ms Idah Seepo, Pharmacist, (Clinical Services MoHW), Mr Stalin Makhathayi, Principal Health Officer, (CHBC Palliative Care Unit), Mr Kananelo Matlanyane, Pharmaceutical Scientist (PMH), Ms Margaret Mmapadi, Pharmacist & Focal Person, Mr Din Mohammad Shaheen Manzurul Haque, Pharmacist (NDQCL), Mr Nick Shamukuni, Pharmacist (Quality Assurance Unit).

While in Uganda, the Botswana team of officials spent time in meetings and learning sessions with key stakeholders in the medicines supply chain for Uganda: Ministry of Health, National Drug Authority, National Medical Stores, Joint Medical Stores, and with APCA jointly with the Palliative Care Association of Uganda (PCAU). The team spent significant part of their time in Uganda at the morphine production site at Hospice Africa Uganda.

In a debriefing meeting with APCA and Hospice Africa Uganda at the end of their visit, Botswana officials highlighted many key lessons learnt and observations made. These included the following.

  1. Seeing the actual production site and process, including the equipment in use helped the team to put into perspective what they should consider in the identification of a production site in Botswana. Participating in the actual production also helped the delegation to come up with estimates of the production equipment that they will require, ideas on who to approach for further technical support and possible funding, as well as ideas to further refine and adapt the processes observed at HAU.
  2. The use of technical and not auxiliary staff was noted (e.g. chemists), and it was observed that Botswana might need to liaise with the Institute of Health Sciences for further capacity building of staff. They also observed the need to include occupational health safety training.
  3. The delegation was happy to observe the Good Manufacturing Practices (GMP) Guidelines being followed at the manufacturing site. The production area was up to standard, and Quality Assurance was effective, so was security along the supply chain. The delegation felt they would request a pre- audit from the Quality Assurance team at HAU before they initiate their own production.
  4. Preparation standards were a learning point, and the mechanism to check seal integrity.
  5. The use of the air curtain was seen as a preferred alternative to a hyper filler.
  6. Objective input was given regarding the bottle washing machines that are in use at HAU
  7. They also observed from home visits to patients in Uganda that community home based care is the key vehicle for delivering good palliative care, especially to the very vulnerable patients.
  8. Waste management issues were also considered, as well as the need for microbiology tests, and possible automation of processes like capping the bottles.

Despite significant differences between the Botswana and Uganda public health systems and population sizes, there was a lot of mutual learning and sharing in the morphine oral liquid solution production process and the supply chain.

The delegation has shared lessons from Uganda with the technical working group and the management team of the Ministry of Health. Preparations for the initiation of oral liquid morphine production and efforts to identify resources for implementing this process have continued.

The African Palliative Care Association is grateful to the Government of Botswana for its efforts towards improving access to palliative care and pain relief for all people who need these services in the country. We are also grateful to the American Cancer Society for supporting this important work in Botswana, and other countries, including: Ghana, Kenya, Mozambique, Nigeria, Rwanda, Swaziland, Togo and Uganda. Thanks to Ms Rosemary Canfua, previously working with APCA and Ms Penny Makuruetsa of the Ministry of Health of Botswana for their leadership of this initiative.

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