Pathways to Integrated Health Systems Strengthening

1. Pathways to Integrated Health
Systems Strengthening
Professor Liz Grant
Director Global Health Academy
Assistant Principal Global Health

2. The quality signatures of a
nation – how it deals with
birth and death
Liz Grant
Living - © Jo Spiller

3. Current systems: we think we know
what to do, but we don’t know how
Concomitant burdens
Infectious, NCD, new ENID,
Poor maternal and child health,
famine, war, climate change,
economic collapse, food insecurity
Health inequalities
urban- rural; gender,
income, education,
Weak health systems
Infrastructure,
governance
technology
HR, financing
Separate systems
We know the
drivers/
vectors but
we have
forgotten how
nimble they
are
What are the
lessons from the past
and the
shared lessons from
other programmes?

4. Pathways to health system
strengthening
• Principles – participation, shared ethos and
values, purpose
• Preparedness - shared vision of change, why it is
necessary, resilience, clear direction, optimism
• Partnerships - clarity on who, why, when, where
• The Planet – not just one more isolated issue –
health is interconnected to who we are, how we
are, why we are here, where our world is going
and what we are moving towards and…….

6. WORLD MORTALITY RATE HOLDS STEADY AT 100%
7 billion people will die
Dealing with dying will help: patients,
relatives, clinicians, NHS, society
2013 20152014

7. We will all die but some of us will die in a
better way than others

8. UHC
Vision
Access to everyone without
financial prejudice
Accessible, available,
appropriate, affordable care
WHO definition of UHC is
about the totality of health
services people need.

9. The added value of palliative care
within a health system to deliver
healthy lives for all
Palliative care brings a deeper understanding of the
vocation within UHC
• Demonstrates not linear strengthening but
relational strengthening
Palliative care asks us to think of the values
underpinning UHC
• The why of care? - palliative care shows the
“heart”
Palliative care models holism -
• rationale for care of the whole person, dealing with
their physical, spiritual, emotional and social needs.
The core
features of
good Palliative
Care (PC) mean
that PC can be
a microcosm of
the best of
practice across
the health
system, and
within the
health service

10. Health Partnership Team INTEGRATE
Integrating palliative care within health systems
Phase 1
Partners: University of Edinburgh, African Palliative Care
Association (APCA), Makerere University PC Unit
working with Ministries of Health (MOH) and National
PC Associations and organisations
• Working in 12 hospitals - 3 identified from each MoH
in Rwanda, Kenya, Uganda, Zambia
• 12 UK and Regional mentorship hubs

11. Strengthening and integrating palliative care into
national health systems
Phase 2
Partnering with Health Ministry in Rwanda
• 6 district hospitals; 3 hub hospitals for clinical excellence;
164 health centres
• Extension and scale up of health systems strengthening
model
• Focused on training and skill sharing, community practice,
curriculum support for under and post graduates.
Uganda
• Development and delivery of leadership fellowship
programme for nurses
• National level research in nurse prescribing and link nurse
roll out

12. Building a Model
Core components
of a Palliative
Care system
Creating the
conditions for
change
Supporting
Sustainable
systems
A proof of concept
A set of system
strengthening
programmes
Evidence based/
evidence generating
programmes:
how to,
what to,
when to
where to
why it matters
Overall added
value
Making visible that
palliative care is
An approach
A service
A system
And that good palliative
care creates a new
paradigm for health

13. Using a 4 Pillar Strategy
to enable participation, to build preparedness, to
establish pathways, to change the paradigm
ADVOCACY –
Palliative care in national health
plans
Greater awareness at all health
service levels and in community
Global recognition
SERVICE DELIVERY –
Palliative care services delivered
in hospitals, health centres,
communities with support and
resources
STAFF CAPACITY – Adequate
number of generalists and specialists
able to provide palliative care within
hospital and health centre networks
PARTNERSHIP –
Strengthened links, active mentorship
programmes

14. Advocacy

15. Advocacy - contributed to
• Inclusion of PC in some
national and district
budgets
• A PC Training
Curriculum developed
Rwanda and Uganda
• Morphine regulation
and registration
• New linkages between
Drug Enforcement
Units and PC providers
• Children’s PC being
recognised
• the WHA Resolutions and WHO
Toolkits
• Multiple World Palliative Care
Day activities
• Adoption of national clinical
guidelines and positioning of PC
in MOH depts in NCD Division
planning
• Inclusion of PC in the Health
Management Information
System
• Nationally recognised protocols
and systems of referral

16. World Health Assembly Resolution
Friday 23rd May 2014
The resolution:
• focuses on health systems rather
than specific diseases
• urges palliative care integration
into health worker training and
education at all levels
• highlights health workers in
oncology, paediatrics, geriatrics
and internal medicine for in-
service training among others
• urges governments to fund
palliative care
• Countries must report

17. Staff
Development

18. Circular knowledge, skills, attitudes,
confidence building
• Basic training a critical mass of staff of different
cadres (supported by clinical placement modelling)
• Advanced training - knowledge on more complex
interventions and care strategies – including research
and children’s palliative care
• Training of trainers in order to cascade training to
others
• Specialist training for future leaders of palliative care
services – BSc, Diploma, MSc training.
• Community training raising awareness of palliative
care among community workers
• Clinical placements – modelling practice

19. Unlocking Staff Capacity: Phase 2
624 professionals trained in
generalist palliative care in district
hospitals, referral hospitals and
health centres nurses, Drs, social workers,
physios, nutritionists, midwives, pastors, dentists,
public health, environmental health, COs.
270 health centres supported with
training, mentoring and
supervision
3 clinical placement sites
strengthened or established RBC and
MPCU staff supported placement sites
174 community health workers
trained
4,000,000 community members
involved in awareness raising
Specialist training programmes
• Diploma in Palliative Care (HAU, Makerere
University, Uganda)
• Degree in Palliative Care (HAU, Makerere
University, Uganda)
6 curriculums developed and 3
implemented
• MMed internal medicine
• Mentorship and supervision
• Support for HBCP programme

20. Integrating palliative care
A PC and pain management
package of services is now
gazetted by law to be provided
in all levels of the Rwanda
Health System.
A separate PC section in the
essential medicines list
identifies 14 medicines with a
variety of formulations
allocated to different levels of
health facility
• Oral morphine in all hospital
facilities.
• A system of monitoring and
supervision includes PC
indicators Integrated
support supervision( ISS)
twice year at all Hospitals
• A separate support
supervision from central
level quarterly
• Ongoing mentorship and
training is in place to
support supervision and
mentoring at all levels

21. Making a difference
..... I will continue to share
with my colleagues who did
not yet attend PC training the
knowledge and working as a
team to help our patients and
their families to live in peace
and cope with illness. Kindly
request for continuous
collaboration for improving
more knowledge for achieving
our objectives which are A
FUTURE WITHOUT PAIN!! ....”
(PC nurse and PC Diploma
student)

22. Training competencies –
with University of Rwanda Masters of Medicine
(MMED) Internal Medicine programme
• What palliative care competencies are needed for
postgraduate doctors to enable them to integrate palliative
care into all their practice?
• What values underpin these competencies

23. Service delivery
Service Delivery

24. Key Components of successful working
models
• Multi-disciplinary / cross disciplinary teams
• Flexible working patterns
• Clear job descriptions with maximum freedom to
innovate
• Planned referral pathways
• Data management systems
• Patient information portals
• Knowledge on broad spectrum of disease care
• Confidence in clinical approach,
• Holistic understanding of patient and informal carer
needs
• Documentation – across specialisms, and between
community, hospital and volunteers
• Shared vision

25. Integration tools - Positioning PC in the
monitoring system
HMIS Indicators for PC
Cumulative number of people
enrolled in palliative care per month
(disaggregated by sex, age and
diagnostics)
Number of New People enrolled in
palliative care at the community
level per month (disaggregated by
sex, age and diagnostics)
Number of patients with
complications referred to health
center per month
Number of Deaths occurring at the
community level per month
(disaggregated by sex, age and
diagnostics)
Number of Morphine vials dispensed
per month
Census of need for PC
Northern hub; CHUK plus
Byumba and Kinihira hospitals
Eastern Hub; Rwamagana plus
Nyamata and Kiziguro
hospitals
Southern hub; CHUB plus
Kabutare and Remera Rukoma
hospitals

26. Improvements in service delivery:
Access to medications
• Improved oral morphine
procurement, distribution
and use in all sites
• Rwanda hosted national
morphine framework
meetings resulting in
456% increase 0
50000
100000
150000
200000
250000
300000
350000
400000
Apr 14-Mar 15 Apr 15 - Mar 16 Apr 16 - Mar 17

27. Improvements in service delivery:
Strategies and frameworks
• 35 strategies, and standards, including referral
documentation, patient registers, assessment forms, clinical
and audit protocols, national training materials and policies.
• 11 new palliative care clinical protocols adapted and
adopted as national documents
Infrastructure and recognition of palliative care
• Designated teams and physical spaces for palliative care
• Needs assessment in 9 hospitals in Rwanda
“Initially we didn’t know we were supposed to take care of pain
for all of a patient’s life. As of now, I have taught the group that
there should be no pain in any patient. … now we are able to
prescribe morphine.” (Doctor, Kenya) .

28. Partnering: Learning through sharing,
listening, giving,
56 mentors spent over 1000 days with colleagues

29. Multi-layered partnerships
driven by champions
A recognition that all that is
achieved is achieved in
partnership
Palliative Care Desk in
RBC -
Diane Mukasahaha
• Partnership included
the funds but the
technical capacity,
skill sharing,
planning, ideas
generation, training
even more
important.

30. Integration: lesson learned
• Capacity building
• Curriculum integration
• Leadership training
• Mentorship
• Research and evidence base
CMF Developing health July
2017
Grant L et al Integrating palliative care into
national health systems in Africa: a multi–
country intervention study June 2017 Journal
of Global Health

31. Integration - the tipping points
• Concurrent Interventions
• Having champions /
“movers and shakers” in
Palliative Care
• A critical mass of staff
• Clarity in the process – a
documented familiar
system of referrals ,
protocols, pathways
• A hospital system of care to
refer to and from
• Community understanding
• Preceptorship – clinical
placement and
mentoring
• Coordinated external and
internal messaging,
• Specialist training linked
to a wider training for all
• Ongoing training
• A movement with
encouragement and
engagement
• A shift in thinking

32. The Pathway: Journeying together in a systematic way
Governance and Leadership - not sporadic but measured and
visionary, management commitment.
Services: Flexible work plans developed to fit within local vision
and current system of care, structures in place
Medicines, Technology, Resources, Space, Protocols
Human Resources: The right sort of training for hospital-
identified teams
• Training is only as valuable as its power to change – so identifying things
that will enable change/ and the stages of change
• Capturing and building on change - dynamic work
• Working with mentors to be a support for implementation, rather than
trainers/ teachers.
A Sharing Learning Network

33. The quality signatures of a
nation – how it deals with
birth and death
@photography jospiller
“Palliative Care
also benefits
other non-
palliative care
patients,
because it is
changing the
system for
everyone”
Waiting - © Mhoira Leng

35. • Telling the story
through the
experiences of people
– incorporating the
problems and the
solutions into the story
(with evidence)
• Conviction of why it
matters and why the
status quo is no longer
tenable once the story
has been told
The legacy: Going forward

36. Thank You
I would like to thank and acknowledge
everyone involved in the different
projects discussed in this presentation