Other myths, for instance that palliative care is just about relieving physical pain or only takes place in a hospice, mean that the broader benefits of integrating this care into health systems are usually only known by those who provide it.
In fact, from reducing hospital admissions to helping prevent illness, integrated palliative care is uniquely placed to bring many advantages to health systems. When efforts are made to expand palliative care from the community level and into hospitals, not only does it help improve referrals into palliative services but it can improve the approach to patient care generally in the institution. According to Dr Liz Grant, who heads up the Global Health Academy at Edinburgh University and was involved in a project to integrate palliative care into twelve hospitals across four African countries, good palliative care that is holistic, with effective logistics and a diverse team, has a broad positive impact across healthcare.
“If palliative care functions like that as a service and an approach to care, then the beauty of that is that it does improve healthcare right across the sector,” she says. “People then think this patient is a person rather than this person has a problem.”
Educating hospital staff in this approach also helps to ensure that this type of care is not limited to specialist areas or only available to patients living with certain diseases. Because one hospital doctor would treat a myriad of people living with different illness, any skills they received in palliative care would impact across the disease spectrum.
“It cascades into other areas,” explains director of programmes at the African Palliative Care Association (APCA) Fatia Kiyange. “Doctors who treat children will also be treating adults. Doctors treating HIV will also be treating TB. Palliative care can definitely cascade across the system.”
As well as its low cost and low tech approach to pain relief, and its tendency to use locally available resources, Kiyange argues that the long term patient centred approach of palliative care means it has big potential to strengthen health systems.
“The patient and family are at the centre of palliative care,” she says. “Care is provided along the continuum, right from the beginning to the end and beyond that for the development of the family. Care is also offered in the setting of choice for the patient and family.”
This focus on the patient and the family also means palliative care providers can help in an area they are not often associated with: preventative care. With a large proportion of Africans never seeing a health worker at all in their lifetime, the opportunities to make an early diagnosis or to educate people about preventing illness are reduced. But because palliative care workers in African countries usually go into a family home to provide care, they have a unique chance to interact with a family, identify health risks and try to prevent them from happening.
Whilst visiting a mother who has cervical cancer, a palliative care worker might be able to identify young daughters who have not had the HPV vaccine and show them how or where to get it. Educating families in sanitation, or identifying those at risk from sexually transmitted diseases such as HIV or Hepatitis B are also opportunities for palliative care workers to contribute to preventative care through their home visits. According to Executive Director of APCA, Dr Emmanuel Luyirika, these workers would be doing a disservice if they just walked away from that situation without acting.
“It’s important to have our eyes and ears open for the families,” he told an audience of palliative care specialists at the APCA/HPCA conference in Johannesburg in September. “We also need to dispel the myth that palliative care providers are too burdened, or too specialised and busy to be involved in the prevention of illness for the patient and the family.”
To harness these benefits, it’s also important to both build an evidence base and ensure commitment from policy makers. At the same conference, calls were made for more research to be done on the relationship between palliative care and preventative care. And garnering political commitment to building standalone palliative care policies in-country was emphasised as essential for integrating palliative care into public health.
“Some countries have done well integrating palliative care into HIV strategies but then people working in non-communicable diseases are reluctant because they think it’s not their business and that’s very dangerous,” says Kiyange. Rather than a scattered approach, standalone policies make it easier to sustain palliative care politically and therefore have a long lasting impact on health systems. “[Countries] need a one point reference where somebody can go for palliative care,” she said. “It needs to be consolidated into one document that can speak for palliative care at a national level.”
Having palliative care firmly represented in national policy makes it easier for services to be integrated and funded at district and hospital level. It’s part of what Dr Grant describes as turning the ‘microcosm’ of palliative care services into ‘macro’, ensuring the benefits of palliative care can be appreciated throughout the health sector.
“Palliative care really captures the real essence of caring and we need to get that out there,” she says. “This is one way a health system can really work – and we have a model.”