Over a year has passed since Rwanda first launched a stand-alone national palliative care policy in April 2011 as the first African country to do so. Swaziland swiftly followed suit.
While formulating a national policy and having it endorsed by the government of an African country entails a lengthy stream of negotiations, Rwanda chose to take a top-down approach in streamlining the process.
In contrast, in many African countries — such as Ethiopia, Kenya, and Malawi — service providers continuously push for governments to embrace palliative care and support its development in more of a bottom-up approach, where policy is developed and informed by practice on the ground.
Both approaches can work.
Rwanda’s palliative care development in the country has been spearheaded by the Ministry of Health, with support from the Palliative Care Association of Rwanda (PCAR) and other local partners, including Partners in Health, Mildmay, the Rwanda Biomedical Center and Intrahealth International.
However, with a shift toward a top-down approach, Rwanda has charted its own course in palliative care provision. In a statement at the first palliative care training where the PCAR was established in 2006, the former Secretary General at the Ministry of Health, Dr Ben Karenzi noted to participants:
“The Government will support a national policy in palliative care and calls upon your participation in developing a national policy. You have full support from us to organise yourselves into a national palliative care association for advocacy – as a mouthpiece of patients and families in government structures, and to establish a network with palliative care colleagues in the region and beyond. The Ministry of Health is happy to work with you to advance palliative care.”
First steps in policy implementation
Following the launch of the policy, a number of trainings of health professionals in palliative care, with the support of the government, took place.
One training initiative focused on the impact of HIV and AIDS through the increase of access to pain relieving medications. The project was coordinated by the African Palliative Care Association in six African countries, including Rwanda, and was funded by the Department for International Development (DfID) through Help the Hospices UK.
Trainees in Rwanda noted that with the policy in place, the government was either initiating or collaborating with other organisations to train health professionals throughout the country.
Addressing drug availability
Drug availability, including pain relieving medications such as morphine, is one part of the four-pronged strategy for developing a pain relief programme recommended by the World Health Organisation (WHO;1990). The other three strategies include government policy, education and training of health professionals, the public, regulators and policy makers — which Rwanda has instituted since the establishment of the policy, and finally, the actual implementation of palliative care services.
According to Dr Christian Ntizimira, the medical director of Kibagabaga Hospital, the policy has not only supported advocacy efforts in the country, but it has also supported other areas such as training, and referrals of patients between health facilities. Of paralleled importance, it has also instilled confidence among health care workers who are providing care to patients and their families facing problems associated with life threatening illnesses.
“We have seen a lot of improvement in terms of awareness about palliative care in the country,” Dr Ntizimira said, “Previously, before we had a palliative care policy in place, it was difficult to provide the service because there were no guidelines, protocols to assist health facilities in managing the service.’’
Through a recent review of progress in pain management through the DfID funded programme in six African countries, a visit was undertaken to Kibagabaga District Hospital in Kigali, where an integrated model for palliative care service delivery has been established.
Explaining that the hospital has integrated palliative care services for both children and adults within the routine daily services offered at the hospital, Dr Ntizimira noted that this approach helps in minimising on costs such as personnel, infrastructure and running expenses that come along with establishing a separate palliative care service organisation.
This is how Dr Ntizimira says the policy was impacting service delivery at Kibagabaga Hospital:
“Being the only hospital in the country that is providing palliative care for both children and adults, we have been given a mandate by the government to train other health care workers in the country in palliative care, invite them to come and experience palliative care delivery at our facility.
We are also receiving patients from other hospitals who are referred to our facility to receive care due to the awareness that has been created. We are not working alone like we used to but we are now working together with other health facilities”.
Kibagabaga District Hospital has also engaged in a memorandum of understanding with PCAR to follow up on the patients in the community after their discharge from the Hospital, thus ensuring a continuity of palliative care services.
Establishment of a national cancer centre of excellence
Another example of the Rwandan government implementing palliative care services is through its recent opening of a modern cancer treatment centre in Burera district in Northern Province. The Centre was formally inaugurated by Former US President, Bill Clinton on 18 July 2012 as a national cancer centre of excellence.
The first of its kind in rural East Africa, the Cancer Centre has included palliative care into its menu of services offered to cancer patients, including chemotherapy, palliative care, screening, diagnosis and surgery, according to an article published in the news website AllAfrica on 27 August. Read about the inauguration of Butaro Cancer Centre.
Assessing the needs to target services
Despite Rwanda’s great strides forward in policy development and training, and efforts to rapidly integrate palliative care into an established health system, the task of making a new policy tangible to the patient is an ongoing process. This is where the support of local, region and international partners are valuable in supporting a government-led initiative.
According to Rose Gahire, the President of PCAR, a needs assessment of palliative care and opioid availability in Rwanda is a crucial step and one of Rwanda’s priorities in ensuring that the government actually acts on what they have agreed in the policy documents. One of the priorities for implementation is an assessment of the need for palliative care and pain management to inform planning.
“There is a need for evidence-based palliative care advocacy. We need funders to support a needs assessment and show the government what we need to do,” she said.