**3. Palliative care-challenges in Nigeria**

The problems militating against the provision of palliative care in Nigeria can be broadly classified into the following:


#### **3.1 Poor awareness**

In Nigeria, 60–70% of patients present to health care facilities with advanced disease, when treatment for cure is virtually impossible [11–13]. Patients are referred late for care and by the time they get to the palliative care center, most of them were already down. The reasons for late presentation include late recognition of initial symptoms due to lack of knowledge, search for alternate treatment and cure, inappropriate advice, poverty and fear of hospitals. Such patients at presentation are at an advanced stage of the disease with several distressing symptoms requiring palliative care.

Many victims of terminal diseases have died as a result of lack of knowledge about palliative care. Statistical data are grossly inadequate and unreliable in Nigeria. The absence of a population-based cancer registry in the country has hampered policy formulation and planning [7]. In a study about knowledge of palliative among medical interns in a tertiary health institution in north-west Nigeria by Nnadi and Singh in 2016, the interns showed inadequate knowledge about palliative care. Among those that reported knowledge about palliative care, many held misconceptions regarding the signs and symptoms and the disease conditions

**85**

*Palliative Care: The Nigerian Perspective DOI: http://dx.doi.org/10.5772/intechopen.85235*

that require palliative care [14]. The sources of knowledge about palliative care were mainly from school lectures and healthcare personnel. This underscores the need to include palliative care in the school curriculum both at the undergraduate and postgraduate levels. The residency training is a critical window of opportunity for training about good end-of-life care for dying patients and their relatives [14]. A similar study in Ibadan, Nigeria in 2002 on the knowledge and attitudes of terminally ill patients and their relatives to palliative care and hospice services in Nigeria, showed gross lack of knowledge about palliative care in our community,

There is also poor knowledge of palliative care among health care workers and reluctance by doctors in Nigeria to prescribe morphine where it is available because of fear of addiction. Morphine remains a controlled drug in Nigeria and in some other countries because of fear of diversion of prescribed morphine. Knowledge gap have also been identified even among health care practitioners that provide palliative care in terms of their understanding of the goals that palliative care seeks to achieve [15]. Financial constraint is given as the major physical factor that prevents

Nigeria is a multi-ethnic, multicultural and multi-religious country. Islam is the major religion in the north, while Christianity predominates in the south. In between there is an amalgamation of Christianity and Islamic religious practices. Despite the practice of these major religions, traditional religious worship reign supreme. The influence of traditional religion permeates the life of an average Nigerian. Religion influences our action, our decision, inspirations, goals, motivations, principles and our contentment. Thus traditional medicine practitioners are well patronized and are usually the first port of call especially in the rural setting. Orthodox medical care is still viewed with suspicion even among the educated class. There is a belief in a diabolical interference existent in almost all illnesses in Nigeria. Accusing fingers are usually pointed to an "envious" neighbor or mate as being responsible even for the slightest form of ill health. The rising trend of the Pentecostal religious movement has not helped matters. It poses a significant means of spiritual or faith-based healing among Nigerians. The health implication is that among many Nigerian Christians, faith healing ministers have taken the place of conventional therapists for their health problems. These confirm that the belief in the efficacy of African traditional healing and church spiritual healing is so strong among Nigerians that they rely on these methods irrespective of some experiences of failures. Thus, many individuals who are unfortunate to be befallen by terminal diseases, attribute their predicaments to witchcraft and spiritual attacks [9]. Many Nigerians don't believe in making their wills until the final moment because of a strong belief in dying by natural means and for fear of being killed by disaffected family members. Thus speaking of impending death is seen as a taboo. This presents a major obstacle in rendering palliative care in our environment. There seems to be a culture of "death denial" among patients, their relatives, and healthcare professionals [16]. Thus having an eye-to-eyeball discussion of impending death with a terminally ill patient may result in stigmatization of the doctor. Suspicion, abuse, rejection of therapy and even signing against medical advice may follow. The patient may then gravitate from one health care facility to another in a futile attempt to get cure. Spiritual homes, faith-based healing centers and herbal remedies would be profusely patronized at a great cost to the patient. When eventually death comes, the family and dependents are left impoverished and unable to foot the burial expenses. Our people hardly accept the reality of failed treatment

but a positive attitude towards palliative and hospice services [4].

the patients from acquiring even their pain medications.

**3.2 Spiritual consciousness**

#### *Palliative Care: The Nigerian Perspective DOI: http://dx.doi.org/10.5772/intechopen.85235*

*Palliative Care*

hospice.

nation health budget.

**3. Palliative care-challenges in Nigeria**

1.Poor awareness, knowledge and skills

6.Lack of government policy/priority

broadly classified into the following:

3.Lack of trained professionals

4.Lack of resources

**3.1 Poor awareness**

requiring palliative care.

Centre Abeokuta, Nigeria. This was the first hospital-based palliative medicine services and the beginning of integrating chronic pain management, palliative and end-of-life care, into an acute care hospital in the country [8]. Through his efforts the country today can boast of more than 15 similar facilities in Nigeria making use of their local institutional policies to move forward. Most families prefer the home-based care. It provides familiar environment, opportunity to attend to siblings, access to family and friends and privacy are advantages. This is performed in conjunction with family, primary care team and specialist within the hospital or

Despite the prescriptions of the WHO in 2002 and its re-emphasize at the 2004 WHO general assembly that palliative care should be integrated into all nations' health care system, several African countries including Nigeria are yet to approve it as a policy. This situation had contributed significantly to the slow level of palliative care development in Nigeria, as the palliative care practitioners have no access to the

The problems militating against the provision of palliative care in Nigeria can be

2.Inability to discuss cancer diagnosis and management with patients

5.Problems associated with availability of medications including oral opioids

In Nigeria, 60–70% of patients present to health care facilities with advanced

Many victims of terminal diseases have died as a result of lack of knowledge about palliative care. Statistical data are grossly inadequate and unreliable in Nigeria. The absence of a population-based cancer registry in the country has hampered policy formulation and planning [7]. In a study about knowledge of palliative among medical interns in a tertiary health institution in north-west Nigeria by Nnadi and Singh in 2016, the interns showed inadequate knowledge about palliative care. Among those that reported knowledge about palliative care, many held misconceptions regarding the signs and symptoms and the disease conditions

disease, when treatment for cure is virtually impossible [11–13]. Patients are referred late for care and by the time they get to the palliative care center, most of them were already down. The reasons for late presentation include late recognition of initial symptoms due to lack of knowledge, search for alternate treatment and cure, inappropriate advice, poverty and fear of hospitals. Such patients at presentation are at an advanced stage of the disease with several distressing symptoms

**84**

that require palliative care [14]. The sources of knowledge about palliative care were mainly from school lectures and healthcare personnel. This underscores the need to include palliative care in the school curriculum both at the undergraduate and postgraduate levels. The residency training is a critical window of opportunity for training about good end-of-life care for dying patients and their relatives [14].

A similar study in Ibadan, Nigeria in 2002 on the knowledge and attitudes of terminally ill patients and their relatives to palliative care and hospice services in Nigeria, showed gross lack of knowledge about palliative care in our community, but a positive attitude towards palliative and hospice services [4].

There is also poor knowledge of palliative care among health care workers and reluctance by doctors in Nigeria to prescribe morphine where it is available because of fear of addiction. Morphine remains a controlled drug in Nigeria and in some other countries because of fear of diversion of prescribed morphine. Knowledge gap have also been identified even among health care practitioners that provide palliative care in terms of their understanding of the goals that palliative care seeks to achieve [15]. Financial constraint is given as the major physical factor that prevents the patients from acquiring even their pain medications.

#### **3.2 Spiritual consciousness**

Nigeria is a multi-ethnic, multicultural and multi-religious country. Islam is the major religion in the north, while Christianity predominates in the south. In between there is an amalgamation of Christianity and Islamic religious practices. Despite the practice of these major religions, traditional religious worship reign supreme. The influence of traditional religion permeates the life of an average Nigerian. Religion influences our action, our decision, inspirations, goals, motivations, principles and our contentment. Thus traditional medicine practitioners are well patronized and are usually the first port of call especially in the rural setting. Orthodox medical care is still viewed with suspicion even among the educated class.

There is a belief in a diabolical interference existent in almost all illnesses in Nigeria. Accusing fingers are usually pointed to an "envious" neighbor or mate as being responsible even for the slightest form of ill health. The rising trend of the Pentecostal religious movement has not helped matters. It poses a significant means of spiritual or faith-based healing among Nigerians. The health implication is that among many Nigerian Christians, faith healing ministers have taken the place of conventional therapists for their health problems. These confirm that the belief in the efficacy of African traditional healing and church spiritual healing is so strong among Nigerians that they rely on these methods irrespective of some experiences of failures. Thus, many individuals who are unfortunate to be befallen by terminal diseases, attribute their predicaments to witchcraft and spiritual attacks [9].

Many Nigerians don't believe in making their wills until the final moment because of a strong belief in dying by natural means and for fear of being killed by disaffected family members. Thus speaking of impending death is seen as a taboo. This presents a major obstacle in rendering palliative care in our environment. There seems to be a culture of "death denial" among patients, their relatives, and healthcare professionals [16]. Thus having an eye-to-eyeball discussion of impending death with a terminally ill patient may result in stigmatization of the doctor. Suspicion, abuse, rejection of therapy and even signing against medical advice may follow. The patient may then gravitate from one health care facility to another in a futile attempt to get cure. Spiritual homes, faith-based healing centers and herbal remedies would be profusely patronized at a great cost to the patient. When eventually death comes, the family and dependents are left impoverished and unable to foot the burial expenses. Our people hardly accept the reality of failed treatment

or death. Their firm belief is that doctors treat and make patients well. The doctor must continue to offer hope even when reality is to the contrary. Where death is accepted, many would want to be at home so that they can make their peace, say farewell, and give final instructions to immediate relatives [9]. Hence one finds that many terminally ill keep away from medical treatment for fear of hospitalization.

#### **3.3 Psycho-social problems**

The model approach to palliative care in the western world differs significantly from the African setting. Palliative care needs in African countries include home and respite care, pain and symptom control, financial, emotional and spiritual support, and also food, shelter, legal help, and school fees. Management of diseaserelated pain in patients with hunger pains highlights the importance of adapting palliative care models from developing countries to African settings. Traditions dictate appropriate models and places of care: sick people might be removed from villages to avoid risk to the community, or returned from the hospital to the community to avoid dangers of overcrowded wards and toxic drugs from developed countries. Access to effective cancer pain relief is hampered by poor social conditions, criminality and urban violence.

There is some social stigma associated with disease entities. Stigma can prevent patients with HIV/AIDS from referring themselves to palliative care.

Many Nigerians would not want to be associated with terminal diseases. They believe that if the public comes to know about their state of health, it would bring dishonor to them and family [9]. The stigmatization that is being shown to victims of deadly diseases in Nigeria, affects the socio-economic progress of the country, as the sufferers probably miss work, and are unemployed or stop-working early. In the mainly Islamic northern part of the country, cultural norms such as Purdah restrictions can prevent women from seeking health care outside the home for themselves. Cultural norms such as traditional practices and use of herbs also discourage the use of more effective modern medical practices. This underscores the relevance of social support in coping with adversity among patients of diverse ethnic origin. In Nigeria, the perception of ill-health is much more complex than the mainstream biomedical approach. The concept of well-being and ill-health is much more holistic, involving the body, the mind and in some instances the supernatural. Thus, superstition, ignorance and cultural practices tend to affect the health-seeking behavior of our people. In our setting, the multidisciplinary palliative care team should include spiritual care givers, family members and friends so as to meet the entire needs of the patient.

#### **3.4 Governmental policy**

Palliative care in Nigeria is still at a developmental stage. Initially the attitude of the Nigerian government towards palliative care was weak and non-committal due to lack of advocacy. Through the efforts of the Hospice and palliative care association of Nigeria (HPCAN), palliative care services have appreciated in almost all the six geopolitical zones of the country. The association has liaised with the federal ministry of health to establish palliative care units in all tertiary health institutions in the country. In addition, the federal government of Nigeria has designated six federal hospitals as oncology centers of excellence.

Despite all these, there remain a lot of challenges in implementation of effective palliative care services in Nigeria. Many cancer treatment centers are located mainly in the urban setting. Thus patients in the rural areas cannot access them due to distance barriers and poverty. Many radiotherapy centers in the country

**87**

understood.

**5. Conclusion**

*Palliative Care: The Nigerian Perspective DOI: http://dx.doi.org/10.5772/intechopen.85235*

Tramadol and Pentazocine, for pain relief.

care should be encouraged and adequately funded.

effective good health care delivery.

**4. The way forwards**

lack functional machines. Even when the machines are available, there is dearth of adequate manpower to maintain them. Morphine, the gold standard medication for pain relief in cancer patients, remains a controlled drug in Nigeria. Due to fear of misuse and abuse, the government is yet to decentralize the distribution of opioids in the country. The Federal Ministry of Health remains the sole importer of opioids, while the National Agency for Food and Drug Administration and Control (NAFDAC) monitors the distribution. The result is that morphine is not readily available to those that need it [8, 9]. Some health workers consequently, have resorted to less effective but more available alternative medications such as

The problems facing the implementation of effective palliative care in Nigeria cannot be excised from the overall prevailing socio-economic condition in the country. Poverty, ignorance, insecurity, poor funding of healthcare, inadequate manpower and poor policy formulation and implementation constitute obstacles to

There is a paucity of information on hospice and palliative care provision in Nigeria and only a weak evidence base upon which to build policy and practice development. Overall, services remain scattered and piecemeal in the country, and coverage is poor. Pioneer workers in palliative care established small models of care to act as foci for education initiatives, so that palliative care can spread to wider areas. They saw in education, as the best hope of contributing care for the dying. It would be wishful thinking to assume that age old beliefs could be eradicated in a twinkle of the eye, but education will create awareness, remove taboos, and modify some attitudes and behaviors. The best way to do this is by incorporating palliative care into the medical undergraduate curriculum and residency training program. Public enlightenment through the print and electronic media will further create awareness; eliminate the stigma associated with terminal illness and regard dying as a normal process. It will provide psycho-social, spiritual and bereavement support for family members. Patients with terminal diseases should be encouraged to seek palliative care at a place best suitable for them. Outreach services for home-based

We need advocacy to present our case to the general populace. Government alone cannot shoulder the responsibility involved in implementing an effective palliative care. The private sector of the economy, corporate bodies, religious and traditional leaders need to be carried along. The government needs to address its policy on availability and distribution of morphine in the country. Palliative care champions in Nigeria are working to demonstrate how morphine access can be appropriately integrated into healthcare systems. Through political advocacy and public awareness, the necessity of integrated palliative care can be better

Both Specialist and integrated palliative care have important role in Nigeria as the "extended family" system is fast breaking down. Grafting palliative care into existing networks of home-based care is feasible and must be adapted to Nigerian needs. Government policy and support, private-public partnership initiative, collaboration with partners is essential to establish palliative care education and

#### *Palliative Care: The Nigerian Perspective DOI: http://dx.doi.org/10.5772/intechopen.85235*

*Palliative Care*

**3.3 Psycho-social problems**

tions, criminality and urban violence.

entire needs of the patient.

**3.4 Governmental policy**

federal hospitals as oncology centers of excellence.

or death. Their firm belief is that doctors treat and make patients well. The doctor must continue to offer hope even when reality is to the contrary. Where death is accepted, many would want to be at home so that they can make their peace, say farewell, and give final instructions to immediate relatives [9]. Hence one finds that many terminally ill keep away from medical treatment for fear of hospitalization.

The model approach to palliative care in the western world differs significantly from the African setting. Palliative care needs in African countries include home and respite care, pain and symptom control, financial, emotional and spiritual support, and also food, shelter, legal help, and school fees. Management of diseaserelated pain in patients with hunger pains highlights the importance of adapting palliative care models from developing countries to African settings. Traditions dictate appropriate models and places of care: sick people might be removed from villages to avoid risk to the community, or returned from the hospital to the community to avoid dangers of overcrowded wards and toxic drugs from developed countries. Access to effective cancer pain relief is hampered by poor social condi-

There is some social stigma associated with disease entities. Stigma can prevent

Many Nigerians would not want to be associated with terminal diseases. They believe that if the public comes to know about their state of health, it would bring dishonor to them and family [9]. The stigmatization that is being shown to victims of deadly diseases in Nigeria, affects the socio-economic progress of the country, as the sufferers probably miss work, and are unemployed or stop-working early. In the mainly Islamic northern part of the country, cultural norms such as Purdah restrictions can prevent women from seeking health care outside the home for themselves. Cultural norms such as traditional practices and use of herbs also discourage the use of more effective modern medical practices. This underscores the relevance of social support in coping with adversity among patients of diverse ethnic origin. In Nigeria, the perception of ill-health is much more complex than the mainstream biomedical approach. The concept of well-being and ill-health is much more

holistic, involving the body, the mind and in some instances the supernatural. Thus, superstition, ignorance and cultural practices tend to affect the health-seeking behavior of our people. In our setting, the multidisciplinary palliative care team should include spiritual care givers, family members and friends so as to meet the

Palliative care in Nigeria is still at a developmental stage. Initially the attitude of the Nigerian government towards palliative care was weak and non-committal due to lack of advocacy. Through the efforts of the Hospice and palliative care association of Nigeria (HPCAN), palliative care services have appreciated in almost all the six geopolitical zones of the country. The association has liaised with the federal ministry of health to establish palliative care units in all tertiary health institutions in the country. In addition, the federal government of Nigeria has designated six

Despite all these, there remain a lot of challenges in implementation of effective palliative care services in Nigeria. Many cancer treatment centers are located mainly in the urban setting. Thus patients in the rural areas cannot access them due to distance barriers and poverty. Many radiotherapy centers in the country

patients with HIV/AIDS from referring themselves to palliative care.

**86**

lack functional machines. Even when the machines are available, there is dearth of adequate manpower to maintain them. Morphine, the gold standard medication for pain relief in cancer patients, remains a controlled drug in Nigeria. Due to fear of misuse and abuse, the government is yet to decentralize the distribution of opioids in the country. The Federal Ministry of Health remains the sole importer of opioids, while the National Agency for Food and Drug Administration and Control (NAFDAC) monitors the distribution. The result is that morphine is not readily available to those that need it [8, 9]. Some health workers consequently, have resorted to less effective but more available alternative medications such as Tramadol and Pentazocine, for pain relief.

The problems facing the implementation of effective palliative care in Nigeria cannot be excised from the overall prevailing socio-economic condition in the country. Poverty, ignorance, insecurity, poor funding of healthcare, inadequate manpower and poor policy formulation and implementation constitute obstacles to effective good health care delivery.
