1. Integrating palliative care into district health services in Malawi
Quality community based care and its role in achieving Universal Health Coverage – Tuesday 22nd November 2016 – Hospice UK, London , 12pm – 2pm

2. The STEP UP project: the Palliative Care Association of Malawi
Service delivery
Training
Education and Prescribing practices
STEP UP aims to integrate palliative care into the public health system in Malawi through its District Hospitals
STEP UP stands for – Service delivery, Training, Education and Prescribing practices.
Aims to integrate palliative care into the public health system in Malawi through the District Hospitals
Began in Malawi’s Southern region in 2011 – originally led by Umodzi, a children’s palliative care service based at Queen Elizabeth Central Hospital.
Staff at Umodzi were concerned about outcomes for patients after being discharged from QECH – they wanted to get good palliative care closer at community level through the 13 district hospitals in the South.
Initial funding – through the Waterloo Coalition – a time limited initiative by 6 international palliative care organisations to catalyse a step-change in palliative care services in Kenya and Malawi. Funding was provided by the Diana, Princess of Wales Memorial Fund and The True Colours Trust.
True Colours provided further funding in 2015 to roll programme out to all the Central and Northern regions – 14 district hospitals.
True Colours’ association with the work began in 2009 when we made a small grant to Umodzi to support patient outreach and follow-up. STEP UP grew out of this initial work – highlights the importance of small grants.

3. Claire asked me to answer the question – what does good community care look like?
This film paints a good picture of what good community palliative care in Africa should look
And who should fund it – the backbone of the service – at least staffing and drugs – should be funded by government

4. STEP UP Outline & Background
A ‘Top down and bottom up’ approach - 4 core objectives:
Increase knowledge and awareness of palliative care among members of the District Health Management Teams - evidenced by the inclusion of palliative care in the District Implementation Plans
Increase knowledge and awareness of palliative care among staff in District Hospitals
Improve the quality of palliative care provided in District Hospitals by increasing the number of people accessing palliative care and appropriate pain relief
Improve palliative care provided outside hospitals by increasing knowledge and awareness amongst home-based care providers and community stakeholders e.g health surveillance assistants, social workers, local and religious leaders and traditional healers
Top down and bottom up approach
Increase knowledge and awareness of palliative care among members of District Health Management Teams – evidenced by inclusion of palliative care in the District Implementation Plans
Activities include DHMT orientation
Educational visits for DHMTs
Increase knowledge and awareness of palliative care among staff in District Hospitals –
training 40 providers in PC
Refresher training for 28
Leadership training
Training health education officers in promoting PC
Clinical placements
Improve the quality and PC provided in District Hospitals
Small grants to renovate PC rooms in hospitals
Mentorship and supervision
M & E at local level and with MOH
Improve PC outside hospital
Train 140 community volunteers, plus orientation workshop for health surveillance assistants, HBC workers etc.

5. The STEP UP project: Outline - funding
First two phases – £424,660 over three years (jointly funded with the Diana, Princess of Wales Memorial Fund)
Third phase – £251,983 over two years (with a view to providing a further two years funding)
Funding
First two phases - £434,660 (jointly with Diana, Princess of Wales Memorial Fund) over three years
Third phase - £251,983 over two years

6. Success
At least a 250% increase in the number of patients accessing palliative care in the South
18 (out of a total of 27) district hospitals now have a dedicated palliative care clinic
Creation of two new clinical placement sites in the South – Mulanje and Mangochi.
Increased knowledge in hospital staff – (in North & Central) average confidence score increased from 3 to 4.5 out of 5
Increased knowledge of palliative care in the community (in North & Central) - average confidence score increased from 3 to 5
1. At least 250% increase in the number of patients accessing PC.
STEP UP’s work in the South ran until the end of In 2013, 2,540 adults and 72 children were recorded as having received palliative care in the Southern Region. By 2014 this had increased to 6,037 adults and 358 children.
2. STEP UP provides hospitals with small grants to renovate rooms as palliative care clinics. In the South they are all open at least once a week with five hospitals having clinics open full time, on a daily basis.
3. Clinical placements are key to ensuring that training is translated into improvements in practice. At clinical placement sites palliative care seems fully integrated ‘the palliative care service has become everyone’s business… such that every hospital worker plays a role to support patients.’

7. Success contin’d
Increase in provision of children’s palliative care
‘I now realise that children need palliative care too. At first I thought palliative care is for adults’
‘I have never prescribed morphine to children. I thought the drug is too strong for them, but now I will be prescribing comfortably.’
Every District Health Management Team has added palliative care to its District Implementation Plan – this means there is a budget for palliative care in every district across Malawi.
6. Children’s Palliative Care
children’s palliative care was not being provided in district hospitals in the North & Central region, it now is. Comments from health workers include:
7. Palliative Care is included in every DHMT’s District Implementation Plan

8. Challenge
Response by PACAM and/or True Colours
National data is poor
PACAM is working with the Ministry of Health to streamline data collection.
National training has focussed on quantity not quality.
PACAM has persuaded Ministry of Health to provide refresher training in the North & Central regions; increase in the number of Clinical Placement sites.
Weak leadership at District level.
PACAM is providing targeted leadership training.
Competing healthcare priorities at District level
Conversations with DHMTs and hospital management; small grants for the creation of palliative care clinics ‘a small amount of pump priming can motivate a district to prioritise palliative care… and raise morale of palliative care staff in the district’.
Poor prescribing practices for pain and symptom control.
Increased focus on mentorship and clinical placements STEP UP’s future years.

9. Challenges and possibilities in supporting the delivery and integration of community based palliative care programmes from a funders perspective
Challenges:
Identifying the right partner organisation – an organisation with an ambitious vision that is able to work at the level of both policy and practice
Competing priorities within healthcare – government, district, local level
Possibilities:
Endless – funders have the opportunity to resource those with a vision, understanding of the local health system and the correct expertise to bring about lasting change
Checklist for integration of services
Challenges
Identifying the right in-country partner organisation – if we want to provide good community services we need an organisation that has experience and influence at the level of both policy and practice
Competing priorities in healthcare –
E.g Lilongwe is the only district hospital without a dedicated palliative care room. A room had been allocated but there was a staff sit-in demanding management speed up hospital renovation – the room originally allocated for PC was taken back for another use.
Possibilities are endless – feeling optimistic but I do think once we have identified the right partners they really are.
Many challenges of integrating palliative care are surmountable – checklist produced by KEHPCA and STEP UP to show how to overcome these

10. Contribution of funders in achieving Universal Health Coverage, including palliative care
Fund initiatives which will integrate palliative care into the public health system - at all levels – and ensure that services have an associated budget line
Work with medical and nursing colleges to ensure that palliative care is included in core medical and nursing curriculum
Fund training and mentoring of health professionals at all levels and cadres
Invest in technologies which improve access to healthcare in rural communities

11. Thank you