Palliative Care, A Reel Challenge in Income and Middle Countries. Example of Morocco

The essence of palliative care is to provide health services for managing patient’s symptoms, reduce their pain, and improve their quality of life. In Morocco, the incidence of cancer is increasing; around 50% of patients are diagnosed at advanced stage. For the majority of them, only palliative treatment and pain relief can be considered. This article is interested on the current situation and challenges of palliative care in Morocco. Currently only three centers devoted to palliative care are functional in Morocco, in Rabat and Casablanca with very restricted bed capacity. The area of coverage is very restricted and palliative care services can be provided by medical or radian oncologists affected in different region of the country, which still insufficient. National Cancer Prevention and Control Plan (NCPCP) make the promotion of palliative care as an important and strategic element of healthcare system, the objective is to be aligned on the WHO recommendations to ensure palliative care and pain treatment for all Moroccans whose need it.


Introduction
Palliative care is a specialized medical care for people with serious illness, it's focused on all care provided which aim to relieve the symptoms of incurable disease, or advanced diseases such as cancer in advanced stages, neurological disorders, victims of road accidents.
The goal of palliative care is to improve the quality of life of patients and support their families, it's consists on medical care (symptom management), psychosocial, and spiritual care.
Palliative care has become an important part of international healthcare systems. In Morocco, the princess Lalla Salma foundation for prevention and treatment of cancer try to make it as a strategic priority.

Current Situation and Needs for Palliative Care in Morocco
Morocco is a North African country, and the population is estimated at 34 million people in 2014, 9.4% of them have than 60 years. It is classified by the World Bank as "upper-middle income country". Morocco's GDP was 185 billion dirhams in 2014 (1USD≈9MAD), and a growth rate estimated to 4.8% in 2015. The budget for the Ministry of Health is around 6% of GDP (Table 1) [1].
In Morocco, the requirements in health cares are still felt. There are six doctors per 10,000 inhabitants, twice less than in Tunisia and Algeria, and four times less than the WHO recommendations. The hospital infrastructure is insufficient to meet the needs of the population [2].
With increasing life expectancy in Morocco, the prevalence of noncommunicable diseases (NCDs) and chronic illnesses are rising rapidly, such as cardiovascular diseases, chronic diseases and cancer, but the prevalence of infectious diseases and malnutrition remains high. Morocco is faced with an epidemiological situation that calls "double burden", marked by the coexistence of infectious and chronic illness [3]. Cancer and cardiovascular failures are the most important of these non-communicable diseases. The annual estimated of new cancer cases in 2014 was 35.000, and around 50% of patients are present at advanced stages, and it's responsible for 7.2% of deaths annually.
This situation reflects a real need for cancer care and especially in palliative care. The management of patients in a palliative setting is an important element of the health care strategy in oncology, and the cancer plan in Morocco makes access to palliative care as an important goal to all Moroccans.
According to WHO estimates for palliative care needs in the region, around 62,000 Moroccans, including 6000 children, need each year palliative care. Moroccan's healthcare system does not have sufficient palliative care capacity to attend to all these patients. Currently only three centers devoted to palliative care are functional in Morocco, in Rabat and Casablanca with very limited bed capacity [5].
The first Department of Palliative Care at National Institute of Oncology, a public hospital, established in 2006 to provide palliative care for hospitalized cancer patients and palliative care training for hospital staff, with a possibility of home care by a mobile team, providing consultations in the region of Rabat. Outpatient services are also available, by opioid's prescription, social and psychological support [5].
The area of coverage is currently limited to the capital Rabat and Casablanca, and there are large parts of Morocco without any palliative care units. However, Moroccan oncologists affected in different parts of the kingdom are trained to provide palliative care and to prescribe oral opioids.
The government healthcare policy makes clear that Morocco is well positioned to take on the important and necessary task of ensuring palliative care and pain treatment for all Moroccans who need it. Developing palliative care is a healthcare priority. In the Sectoral Health Strategy (SHS) for 2012-2016, and a National Cancer Prevention and Control Plan (NCPCP) for 2010-2019 (in collaboration between the ministry of health and Lalla Salma foundation); palliative care is one of the strategic axes, the objective is to be aligned on the WHO recommendations [3].
In 2013, Morocco changed the law concerning the distribution of the morphine by increasing the number of day's prescription for opioid analgesic (7 to 28 days), currently the prescription can cover from 7 to 28 days, removing a key barrier to availability of these medicines [5].
The NCPCP identified major problems to access to palliative care in Morocco: • Insufficient training of healthcare workers in the palliative care field • Lack of human resources: doctors, nurses, psychologist, physiotherapists, and auxiliary nurses • Lack of centers adapted to provide general and terminal palliative care • Insufficient follow-up of the patients after return to the home • Absence of supportive care and civic culture regarding end-of-life and death issues [3].

Regional Availability of Palliative Care
Palliative care development is particularly weak in low and Middleincome countries.
The largest part of countries in north-Africa and middle-east was considered as countries with capacity building activity in palliative care or with isolate palliative care provision (Table 2) [6].
The most important barriers to access to palliative care and pain treatment in the majority of low and middle-income countries are the lack of health policies in support of palliative care development, the lack of human resources and the poor accessibility to essential palliative care drugs.

Perspectives
The oncology in Morocco has experienced great progress during the last ten years. The princess Lalla Salma foundation for prevention and treatment of cancer has an important role to improve cancer cares, in terms of access to medical structures, availability of medicines and training of healthcare professionals, especially in palliative care. The first palliative workshop was organized in collaboration with the American society of clinical oncology at Fez in April 2015, which aims to train Moroccan doctors to palliative cares and management of pain.
WHO noted that simple measurements will be fundamental for the development of palliative care, and "a little cost can allow a significant effect" [9].
WHO recommends that countries integrate palliative care at all levels of their medical departments, including the community level.
Morocco's cancer plan attempts to decentralize and democratize access to palliative care, ensuring the management of patients in regional cancer centers; in lowers healthcare units, and develop mobile team units [9,10].
The cancer plan was interested to development of a strategy of palliative care by introducing 13 measures, focusing on the evaluation and management of pain, by institutionalizing its treatment at all levels of healthcare system, promote opioid's prescription, assure social and family support, help patients and families in the last stage and end of life, and promote research on palliative care [3].
The objective of the NCPCP in terms of palliative care is to have a national and regional experimented network, so as to take care of all the patients in palliative situation, and to support the patients and their family in this delicate and specific stage of the disease [3].
The organization of the palliative care will be access on a policy of regionalization of care, every region will have a focal point of care, with a unit of palliative care and a mobile team (a doctor, a nurse and a psychologist…) insuring the management of patients at home, and transport the patient for palliative care unit if necessary (Figure 1) [11].

Conclusion
In few years, the increase of incidence of cancers will be observed in Morocco, most of cases are diagnosed in advanced stage of disease. This situation shows the real need on palliative care.
Currently palliative care services in Morocco still limited, and large part of population has no access to this care. The Moroccan government in collaboration with the princess Lalla Salma for prevention and treatment of cancer adopted a national plan against cancer, in which development of palliative care is an important priority. The goals of this plan are to decentralize and democratize palliative care for all Moroccan whose need it, with new approach of organization of care.