The Palliative Care Association of Malawi (PACAM) has been central in supporting the integration of palliative care in Malawi’s public health systems, including its integration in national policies and guidelines, education curricula, health services, as well as efforts for improving access to pain medications. Significant progress has been realised to date as PACAM has continued to lead advocacy efforts and to provide technical assistance to all palliative care stakeholders in Malawi, in collaboration with the Ministry of Health and,
The Malawi Ministry of Health was among the first in Africa to recognise the value of integrating palliative care in its health system, especially as it reduces health-related suffering through increased accessibility and sustainability of health services coupled with reduced workload and integrated comprehensive care provision.
At the policy level, PACAM has worked with the Government of Malawi over the years, and with support from partners such as the African Palliative Care Association (APCA), has ensured that HIV, Cancer and other Non-Communicable Diseases and conditions requiring palliative care are part of the Essential Health package (EHP), and therefore are reflected in the national Health Sector Strategic Plan.
In 2012 Malawi saw the development of its national Palliative Care Guidelines, and in 2014, the national Palliative Care Policy was developed to guide service delivery throughout the country. Subsequent health related policies and guidelines such as the NCDs Action Plan now mainstream palliative care. To ensure standardization at national level, palliative care indicators were incorporated into the National District Health Information System (DHIS2) and the indicators are being tracked nationally. Palliative care was also integrated into medical and nursing curricula in universities and schools of health and allied sciences and is examinable. In 2018 the University Of Malawi College Of Medicine introduced a BSc degree programme in palliative care and the first cohort of 20 graduated in 2021, and in 2022, Malawi modified and adapted the APCA Palliative Care Standards and came up with the Malawi Palliative Care Standards.
Malawi has also been working to ensure that we have adequately trained and skilled human resources to provide palliative care services. About 100 medical doctors, 2,000 clinical officers, 3,000 nurses, and 300 pharmacists had been trained in a course on Introduction to Palliative Care and Holistic Pain Assessment and Management Using Opioids to date. Also, 100 health care workers completed the post graduate bachelor’s degree in palliative care from other universities outside Malawi, while 5,000 home based palliative care volunteers were trained as palliative care providers and are supporting palliative care patients in the rural communities. Many of these have been recipients of palliative care scholarship funds from Global Partners in care and APCA.
To ensure access to essential medicines for palliative care, the Government through Central Medical Stores Trust procures morphine and other essential medicines for pain and symptom control, and they are regularly available and offered free of charge to patients. A functional drug advocacy taskforce is available in the country led and supported by PACAM.
To ensure sustainable access to palliative care services, the Ministry of Health has a Palliative Care Department led by a designated full-time officer who coordinates palliative care services nationally, together with District Palliative Care Coordinators in all districts. Currently 108 public hospitals have integrated and are providing palliative care services.
Challenges and possible solutions
Though Malawi is a signatory to a number of international conventions such as the Abuja Declaration which calls on African Governments to increase their budgetary allocation to health to at least 15% the national budget, the country has yet to achieve this target, and hence the allocation for palliative care is equally affected.
In recent years, a number of donors have shifted their funding priorities from palliative care programs due to the misconception that all HIV & AIDS patients have improved with ART support and there are no bedridden patients or patients in need of palliative care. Consequently, a number of palliative care organisations had to phase out their palliative care programmes, leaving many patients without support and some desperate.
The108 health facilities where palliative care has been integrated are largely urban. The service is still not available in rural areas where 85% of Malawi’s population live. It therefore remains expensive and mostly impossible for rural patients with palliative care needs in areas to access such services when needed.
Another challenge is in the supply chain where in some cases, palliative care essential medicines run out of stock including morphine, thereby leaving many patients who rely on the medicine in severe pain.
There is also constant attrition as trained and well qualified palliative care providers change jobs to non-palliative care organisations in search of greener pastures since there are few or no incentives in palliative care.
Some health facilities don’t have adequate physical space to accommodate palliative care service delivery as a result services are offered on alternate days with other programs.
Many patients are poor and too sick to actively involved in household food security activities as such they lack nutrition support.
PACAM is using its influence and recognition by the authorities to advocate and lobby with the government to bring palliative care needs to the forefront for issues like capacity building of the sector. There is limited financial support resources to enable the National Association to adequately engage, advocate and lobby with the Government to support palliative care programs from human resource development and regular procurement of essential palliative care medicines.
PACAM also looks to benefit from regional and global palliative care advocacy from bodies like APCA, WHPCA, GPIC, and IAHPC to international donors such as to understand and prioritise palliative care.