World Cancer Congress, August 2012, Montreal, Canada Palliative Care and Health Systems Strengthening in Africa Fatia Kiyange Director of Programs African Palliative Care Association Kampala, Uganda
The presentation ! Overview of Palliative care and health systems strengthening (HSS) ! PC role in HSS – current situation, best practices, suggestions & recommendations
What is palliative care? � An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. � (WHO, 2002)
Palliative care for children Palliative care for children represents a special, closely related field to adult palliative care. Palliative care for children is the active total care of the childs � body, mind and spirit, and also involves giving support to the family.
Principles of palliative care: • Provides relief from pain and other distressing symptoms; • Affirms life and regards dying as a normal process; • Integrates the psychological and spiritual aspects of patient care; • Offers a support system to help patients live as actively as possible until death; • Offers a support system to help the family cope during the patient’s illness and in their own bereavement;
Palliative care: • Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated; • Will enhance quality of life, and may also positively influence the course of illness; • Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life
WHO enhanced Public Health model for Palliative care (Stjernsward, 2007)
(Stjernsward, 2007)
WHO Palliative Care Program Principles ! Developed as a comprehensive and public health approach ! Integrated with existing health systems and the continuum of care for chronic, life-threatening illnesses ! Tailored to the specific cultural and social context.
How would you describe such a health system?
‘ There is tendency to believe that a long and healthy life is the right of those who can afford it- this is totally wrong, the reality is that our people are dying in large numbers’ . We are running a health care system that is not working! The solution is re-engineering the country’s primary health care system ’ ( Minister of Health, South Africa, June 2011) .
UNAIDS recognizes that effective AIDS responses need stronger health systems to reach universal access to prevention, treatment, care and support services. PEPFAR emphasises incorporation of health systems strengthening goals into its prevention, care and treatment portfolios to help reduce the burden of HIV/AIDS on the overall health system .
Health systems?? Health systems are : all organisations, people and actions whose primary intent is to promote, restore or maintain health – including efforts to influence determinants of health as well as more direct health- improving activities.
‘The best measure of a health system’s performance is its impact on health outcomes’
Outcomes, mediated through access , coverage, quality and safety ,
A good health system ! Delivers quality services to all people, when and where they need them and requires; ! a robust financing mechanism; ! a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; ! well maintained facilities and logistics to deliver quality medicines and technologies
A well functioning health system • Balances population’s needs and expectations by: – providing equitable access to people-centred care where they need it – improving the health status of individuals, families and communities – defending the population against what threatens its health – protecting people against the financial consequences of ill- health
WHO HSS Framework The six fundamental building blocks of a generic health system include: – service delivery – health workforce – Information – medical products, vaccines and technologies – financing; and – leadership and governance
Health systems building blocks & WHO enhanced public health model for PC • Palliative care policy (financing, Leadership and Governance, information) • Education (Health workforce development, information) • Drug availability (vaccines and technologies Medical products) • Implementation (service delivery)
PC & HSS – the situation in Africa ! Big potential for strengthening health systems: - Aligned with WHO definition of health - Holistic approach - Using locally available resources - Patient and family focus - care for care givers - care along the continuum - care in setting of choice
Palliative care policy (Financing, Leadership and Governance, information) ! Strategic policy frameworks – NCCP, NCD strategies, PHC, stand-alone policy, older people, national PC strategic plans etc ! Effective oversight, coalition-building, regulation, attention to system-design and accountability ! Financial commitment for PC ! Defined structure for PC integration – review, reorganization, staff roles, levels of integration ! Sustained political commitment
Palliative care policy (Financing, Leadership and Governance, information) ! National guidelines and protocols for PC, use of opioids, standards etc ! Defining appropriate models – hospital, home care ! MOH accreditation for PC sites ! Identifying home department/directorate for PC – NCDs, HIV/AIDS, HBC, clinical services, PHC? ! National PC steering committee/taskforce ! National coordinator/desk ! Monitoring & evaluation – indicators, referrals
Drug availability (vaccines and technologies Medical products) ! Availability of PC medications ! Accessibility at all levels of service delivery ! Inclusion in national essential medicines list ! Formulations e.g. opioids ! Rules & regulations for use e.g 10 day rule ! Prescription laws, task shifting
Drug availability (vaccines and technologies Medical products) ! Addressing barriers on use ! National guidelines on use of opioids ! Cost versus equity ! Cancer treatment centralized in most countries ! Public awareness
Education (health workforce development, information) ! Over 50 countries globally have critical shortages in health human resources. ! 36 are in SSA, where there is 11% of the world population, 49% of the global disease burden and only 3% of the world’s health workers ! Estimated to be 2.5 million doctors, nurses and midwives, or 4 million health workforce , including managers and other public health workers. ! Poor doctor patient ratios; Uganda - 1:15,000 compared to WHO recommednded1:10,000 for Africa ( New vision, Aug 2012) ! Nurse to patient ratio of 1:11,000
Education (health workforce development, information) ! Understanding of PC, skills, attitudes ! Staff numbers ! Fair distribution ! Competent ! Productive & responsive ! Multidisciplinary
Education (health workforce development, information) ! Trained – generalist & specialist ! Community care providers ! National PC training packages ! Training on use of opiods ! Integration in in-service and pre-service training ! Work loads ! Brain drain ! Deployment issues
Implementation (Service delivery) ! Approach and models of delivery –highly specialized vs generalist ! Integrated – HIV/AIDS, Cancer & other NCDs, general services, specialist clinics, pediatrics ! Public/private partnerships ! The minimum package for PC ! Monitoring and evaluation – tools, documentation, data collection etc
Implementation (Service delivery) ! Collaboration, networking & referral – silos from specialization, disease and component specific etc ! Patient and family involvement ! Mulitisectoral approaches vs single sector ! Decentralization e.g cancer treatments ! Community care giver models – formalizing ! Care for carers programmes
Reflection ! Can Palliative care play a central role in: - re-engineering health systems? - strengthening HSS? ! What is your role in making this happen? ! Who else needs to be involved? ! What help is needed?
Refs • World Health Organization: Health systems framework, 2007 • World Bank-Global Disease Burden statistics • World Palliative Care Alliance- Health Systems and Palliative Care Policy paper • APCA Strategic Plan 2011-2020 . • Mwangi-Powell (2008)Health workforce shortages in Africa, the BMJ • Cecilia Sepulveda. From Concepts to Reality: Palliative Care in Resource-Constrained Settings for People Living with HIV and Other Life-Threatening Illnesses: The World Health Organisation Approach
Acknowledgement Dr Faith Mwangi-Powell, Outgoing Executive Director, African Palliative Care Association
BOOK THE DATES
African Palliative Care Association PO Box 72518 Kampala Uganda T: +256 414 266 251 F: +256 414 266 217 E: info@africanpalliativecare.org W: www.africanpalliativecare.org
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