In December 2009 at Kibagabaga Hospital, Dr. Christian Ntizimira and Dr. Olive Mukeshimana, with a group of nurses and social workers decided to discuss the integration of palliative care in all services in the hospital. This was a new concept in Rwanda.
Five years later, Kibagabaga palliative care center (for adults & children) has become a center of excellence in palliative care. This is a result of teamwork, advocacy, good leadership as well as government support.
Located in Gasabo District, one of the biggest districts of Kigali, the hospital has a catchment area that covers 60% of the total population of Kigali. The hospital supervises 16 health centres, 18 post heath centres 489 villages and 1467 community health workers. 85% of population use community based health insurance, “Mutuelle de santé”, and 15% private insurance.
Kibagabaga Hospital was among 5 districts hospital designated by the Ministry of Health to start a pilot project of palliative care supported by Intrahealth/Mildmay in 2008. The number of patients was huge, lack of trained health providers and inexistent integrated services were identified as potential challenges.
Before integration of palliative care
Before the hospital integrated palliative care in all services, the concept of this comprehensive approach was only for end-of-life care. The statistics showed that chronic disease was a burden in all departments of the hospital:
- Average of morphine used per year was 5%,
- Bed occupancy rate: 120%,
- Death rate: 3%,
- Average of length of stay: 6 days
- More than 90% of patients were suffering from moderate and severe pain.
- Psychosocial support inexistent
- Lack of support for children and their families
- Lack of personnel trained
Looking back it is now clear that the two big challenges were myths and procedure to prescribe morphine. At the end, patients preferred to die at the hospital more than in the community.
Success of integration of palliative care
After palliative care was integrated in all services, the objectives were to improve the quality of life for patients, reduce cost and increase value. The journey took five long years before the effort of a team being recognized as centre of palliative care in Rwanda. The impact has been huge:
- Bed occupancy rate dropped to 80%
- Average of length stay is now just 4,1 days
- Death rates decreased at 1,5%
- Morphine’s prescription increased among physicians trained to 26%
- The number of children treated moved to 27 in 2009 to 273 children in 2012
- The MDT trained increased from 10% in 2009 to 40% in 2012
- Anecdotal data indicates a high level of satisfaction by patients and family members with services provided and a reduced tendency of patients with end-stage diseases to pursue costly treatment abroad.
A study done at Kibagabaga Hospital from 153 reviewed patient registers & charts enrolled in palliative care services between January 2010 and December 2012 showed the following results:
- 58% were women and 42% men
- Cancer came on the top of disease with 84% of patients (Hepatocellular carcinoma: 23%, Gynecologic: 18,6 and Others: Head&neck, Skin, Hematologic, breast, lungs, GI, GU, Brain: 71%)
- The average age of patients is above 60 years old (38%)
- 76% of patients have been discharged and followed at home compare to 18% preferred to die at the hospital and 9% have been referred to high level hospital.
Multi-disciplinary palliative care is rarely integrated into the public healthcare system in Africa. In Rwanda, Kibagabaga Hospital developed adult and paediatric palliative care services in an urban general hospital and linked these services to home care. Home care is provided by a private home hospice organizations, and government-employed community health workers are now being trained in palliative home care.
After hospital discharge, most of our patients receive follow-up care at home and report a high level of satisfaction. It is feasible to integrate palliative care into public healthcare systems in Africa
The Rwanda Ministry of Health has done a lot in Non-Communicable Diseases and palliative care by approving the national policy, strategic plan for four years and implementation. It is our duty to implement the policy at each level of health system, district hospital, health centre, post health centre, and villages.
Even if Kibagabaga became a centre for palliative care and we doubled our quota of morphine, we are still facing many challenges: drug availability, turnover of personnel trained, and lack of supervision in home-based care. A survey showed that more than 85% of our patients still suffer from moderate and severe pain, palliative care must be considered as human right –accessible to all.