Morbid but fascinating: The Quality of Death Index, where South Africa and Uganda lead, and Nigeria trails

Uganda's government now supports the availability of oral morphine to anyone who needs it for free.

EVERYBODY likes a bit of competition, so the index business is all the rage these days – there are indexes out there that rank countries on corruption, fragile states, governance, human freedom, doing business, competitiveness, and so on.

We at Mail & Guardian Africa have come up with a few quirky ones of our own: The Africa True Business index, the Africa Big Man Health index, the Anti-Fragile index, the Theft index, the Cigarette Smoking index, and others.

But here’s one index you probably never knew existed – the Quality of Death Index, which ranks countries by the quality of palliative care.

The Index, compiled by the Economist Intelligence Unit, highlights the advances that countries are making in taking care of their citizens at the end of life, as well as the remaining challenges and gaps in policy and infrastructure.

It’s morbid, but important stuff – although Africa is still overwhelmingly young, the proportion of older people in the population is rising, and non-communicable diseases such as heart disease, diabetes and cancer are on the rise. The need for long term, palliative care is also therefore set to rise significantly.

The index ranks countries across five categories: the healthcare environment (government spending, regulation and policy), human resources, affordability of care, quality of care and the level of community engagement. Thirteen African countries were included in the index.

South Africa tops the overall African rankings in the quality of end-of-life care, with a score of 48.5 out of a possible 100. Uganda comes in second, at 47.8 and Ghana is third, at 34.3.

Although in the global rankings there is a strong correlation between income levels and success in delivering palliative care services, the link is weaker in the African context.

Marginally better
Nigeria – Africa’s biggest economy – comes in last (13th) in the quality of palliative care, with a score of just 16.9; Botswana, Africa’s sixth-richest country by per capita GDP, performs marginally better at 12th place (score 22.8), and Ethiopia, Africa’s fastest growing economy is in position 11, with a score of 25.1.

Countries with a high “quality of death” share several characteristics, the EIU highlights, including a strong and well-implemented national palliative care policy framework, high levels of public spending on health care services and medical workers who are well-trained on palliative care.

They also have generous subsidies to relieve the financial burden of palliative care on patients, wide availability of opioid painkillers such as morphine, and strong public awareness on palliative care.

Uganda is the star performer in the Index, considering its relatively small economy. Ranked second overall, Uganda beats all the other African countries in the training and skills of its medical workers to deliver end-of-life care; second in the quality of care received, and fourth in supportive policy and regulatory framework.

Africa Quality of Death index
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When it to the availability of morphine, Uganda has made striking advances in pain control through a public-private partnership between the health ministry and Hospice Africa Uganda, a pioneering institution founded by Anne Merriman—a nominee for the 2014 Nobel Peace Prize.

“The government now supports the availability of oral morphine to anyone who needs it for free,” said Emmanuel Luyirika, executive director of the African Palliative Care Association, quoted in the EIU report.

But Uganda still lags behind in affordability of care, coming in position 9 in this indicator. The richer African countries – by per-capita income – do better in this indicator, which measures the availability of public funding for palliative care, the financial burden palliative care places on patients, and the availability of coverage through national pension schemes. 

Charitable funding
In many countries, affordability of care comes thanks to charitable funding. In first-placed South Africa, in addition to government funding, the country has a strong non-governmental hospice movement— offering both outpatient and in-patient services—under the Hospice Palliative Care Association of South Africa. Religious institutions also have hospitals that offer palliative care.

South Africa has developed a highly integrated model of palliative care through its hospice movement, said Richard Harding, who developed the African programme for Cicely Saunders International,an NGO focused on research on and education about palliative care at King’s College London. 

“Their hospices don’t just focus on end-of-life care,” he says. “They are out in the community providing TB control, family education, diagnosis, infection control and going into clinics to provide basic HIV care.” In fact, patients from neighbouring countries such as Swaziland, Namibia and Botswana often travel to receive care in South Africa.

It appears that countries with a high prevalence of HIV/ Aids have a better-developed palliative care system, because the need to provide long-term, home-based care is very much a part of HIV management. 

This would seem to be the case for South Africa and Uganda, but it is not so for Botswana, which has one of Africa’s highest prevalence of HIV, but is only second from last in the rankings.

While South Africa is not the strongest performer in the Index in the human resources category (it is at position 8 in Africa), in many ways, it has forged ahead in training and skills provision; the first master’s degree in Africa in palliative care was offered by the University of Cape Town.

The country’s other strength, according to the report, lies in its long history of integrating palliative care into training for those working in family medicine departments.

Normal process
But there’s an opportunity for developing countries can move forward relatively rapidly because of the absence of entrenched systems.

“African countries have succeeded in delivering high quality effective palliative care in the face of low resources and overwhelming need,” said Dr Harding. “And high- and middle-income countries would be wise to learn lessons from them.”

Despite improvements, much more needs to be done, the report indicates. Even top-ranked nations currently struggle to provide adequate palliative care services for every citizen.

“Cultural shifts are needed as well, from a mindset that prioritises curative treatments to one which values palliative care approaches that regard dying as a normal process, and which seeks to enhance quality of life for dying patients and their families,” the report concludes.


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