At the end of last year I was fortunate to meet Dr Christian Ntizimira, a palliative care specialist from Rwanda who was on a visit to Scotland as part of the THET programme.
The opportunity to discuss palliative care policy and approaches in Rwanda drew my thoughts to comparisons closer to home, as Scotland looks to develop a new national strategy.
Rwanda’s national policy
In 2011, Rwanda was the first African country to launch a national palliative care policy. The policy is committed to ensuring that everyone living with a terminal illness is able to access high quality, affordable palliative care services to meet their physical, psychological, social and spiritual needs by 2020.
This includes clinical guidelines as well as a commitment to provide palliative care training to all consultants and community workers. Christian was quick to point out that – although the policy is being delivered by the department for health – there has been a broad acceptance by health professionals delivering care locally. Greater palliative care training for all healthcare staff regardless of speciality is something that Marie Curie is keen to see more of in the UK.
What is interesting to hear is that palliative care in Rwanda was not driven by cancer, which has been the case in many European countries including the UK, but by HIV.
People in Rwanda are now living longer and more people are experiencing life limiting conditions such as cancer, heart disease and diabetes. Their approach to palliative care will have to adapt to meet those increasing needs, especially if they are to meet their 2020 target.
‘When you are well you belong to yourself, when you are sick you belong to your family’
Care in Rwanda is clearly built around the family, with the societal mantra: ‘when you are well you belong to yourself, when you are sick you belong to your family’.
Christian discussed that when caring for a sick patient, he often has to deal with large numbers of family members who all become involved. This can be quite different to our experience in Scotland, where it is more common that there are only one or two family members who act as carers.
Hearing where people want to be cared for and die in Rwanda highlights some interesting differences with Scotland. Many families in Rwandan cities prefer for their family members to be cared for and die in hospitals.
This is because hospital care is seen as an important reflection of wealth and success as a family can afford to pay for their loved ones to be cared for, rather than being forced to care for them at home or to rely on financial help from the state.
This is very different to our views in Scotland, where the vast majority of people would like to be cared for at home and die there rather than in a hospital, which is often seen as people’s least preferred option.
Care in the community
A great deal of focus, Christian explained, is on providing care in the community, particularly in rural settings. This is an interesting comparison for us where rural Scotland covers 95 per cent of the land area and 18 per cent of the population.
In rural communities in Rwanda, many people now chose to receive their care at home. This in stark contrast to the situation before the country’s national palliative care policy came into force, where dying patients would nearly always prefer to be in community hospitals.
The big difference the national policy has made has been in making available oral medicines to control pain and symptoms.
Hope for the future
Christian paints a very positive picture and it is clear that he is very hopeful for the future. He does agree that there is still progress to be made, but is quick to point out that with the Government of Rwanda firmly behind the strategy there is every chance that the national policy will achieve its aims by 2020.
Having spoken to Christian it is clear that when we look to develop our responses to the unmet need in caring for people with palliative care needs we should look far and wide for inspiration.
In Scotland we are currently developing a new framework for action for palliative and end of life care and it would be great to see a similar ambition of ensuring that everyone by 2020 who needs palliative care has access to it.
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