Recently, Rwanda officially launched its national palliative care policy, making it one of the first countries in the developing world to do so. As Priya Shetty wrote last year in the Lancet, “Palliative care is almost unheard of in the developing world, condemning millions to agonising deaths each year,” which she mentions some equate as “tantamount to torture” [1].

Rwanda’s new policy commits the country to providing all Rwandans living with an incurable illness with high-quality, affordable palliative care services to meet their physical, psychological, social, and spiritual needs by 2020. Appropriate care for the chronically ill and dying, as well as for their families, is a critical part of palliative care. Another crucial aspect is providing health workers and caregivers with the training, guidance, and tools they need to offer this care.

"The launch of the policy is a significant milestone in the provision of health care in Rwanda and will bring relief to our countrymen and women suffering from incurable diseases,” said Dr. Eugene Ruberanziza, Ministry of Health expert in charge of communicable and non-communicable diseases. “Quality end-of-life care in Rwanda is no longer just an aspiration; the new policy provides us with the legal framework to make it a reality."

Palliative Care Requires a Paradigm Shift for Health Workers

For many health workers, offering palliative care requires a paradigm shift in their thinking and approach from seeking curative solutions to offering care and support to ease the pain, suffering, and symptoms of chronic or incurable illnesses. The new national policy is an important first step in creating a system for offering this care, which includes a steady, closely regulated supply of pain medication as well as pre-service and in-service training for health workers.

As in many developing countries, people in Rwanda are living longer. Average life expectancy has increased to nearly 51 years, up from 46 years in 1980 and following a dramatic drop in life expectancy in the 1990s during the height of the HIV epidemic. Today in Rwanda, it is estimated that nearly 3% of adults are living with HIV, but with the availability of antiretroviral treatment, many of them will live longer, healthier lives. This rise in life expectancy combined with changes in lifestyle also means that more people in the developing countries are experiencing chronic illnesses such as cancer, heart disease, diabetes, and respiratory illnesses [2,3].

As a result, health workers need to be better equipped and trained to respond to prolonged illness that may be incurable. In particular, the Rwandan policy states that palliative care should affirm life, neither hasten nor postpone death, and regard dying as a natural occurrence. It also requires a qualified health worker, professional, or team to offer:

• Relief from pain and other distressing symptoms
• Integrated psychological, spiritual, and patient care
• A support system to help patients live as actively as possible until death
• A support system to help the family cope during the patient’s illness and in their bereavement.

Health Systems Must Shift to Provide Palliative Care

The national palliative care policy defines Rwanda’s concept of palliative care and the package of services included in this care. It also specifies the roles and responsibilities of professionals in offering palliative services at hospitals, other health facilities, and in home-based care. The policy outlines the tools, guidelines, and protocols needed to act on the new palliative care standards, including laws to govern the use of prescription opioids for pain (e.g., morphine) and ensure their regular supply. The policy defines the need to monitor and evaluate the quality, accessibility, and impact of these services on patients’ health and well-being and offers a model for providing patients with a continuum of care from one type of provider to the next. Rather than requiring substantial new investments, launching the new policy will demand some readjustments in the health system to realize the standards set forth in new guidance.

The new policy is the culmination of many years of work, starting in 2004 when the Rwandan Ministry of Health sent a team to Uganda to learn about the new Ugandan palliative care delivery system and began creating its own holistic and integrated HIV/AIDS program. In 2005, Rwanda started training health workers in palliative care in collaboration with a number of partners. The Ministry began developing the national palliative care policy, protocol, and strategic plan with the support of partners in 2008. The following year, Kibagabaga Hospital in Gasabo District opened the country’s first pediatric palliative care center, followed by a new palliative care ward for adults late last year. Although some Rwandan health facilities had previously offered services that are considered palliative care—such as pain management and bereavement support—only recently have health centers started to establish specific palliative care units for patients in need of continuous support.

The work has been accomplished through many partnerships between the Rwandan Ministry of Health and other organizations, which include the Society of Women against AIDS; Help the Hospices UK; the African Palliative Care Association; the  USAID-funded, IntraHealth-led HIV/AIDS Clinical Services Program; and Mildmay International.

References                  

1. Shetty, P. 2010. The parlous state of palliative care in the developing world. The Lancet 376(9751): 1453 – 1454.
2. Nugent, R. 2008. Chronic diseases in developing countries health and economic burdens. Ann NY Acad Sci 1136: 70–79.
3. Nabel E.G., S. Stevens, R. Smith. 2009. Combating chronic disease in developing countries. The Lancet 373(9690): 2004-2006.