BUILDING MOMENTUM

FOR GLOBAL PALLIATIVE

CARE: HEALING NATIONS Dr Liz Grant

Assistant Principal

University of Edinburgh

Director Global Health Academy

From the Lancet Commission

Anthony Capon

“We, the Peoples”

An agenda of the people, by the people,

and for the people - the road is

mapped

It will be for all of us to ensure that the

journey is successful.

intercultural understanding,

tolerance, mutual respect, and an

ethic of global citizenship and

shared responsibility.

Global Health Academy

Themes of the 17 goals

People

• End poverty and hunger, in all their forms and dimensions, Ensure everyone can fulfil

their potential in dignity and equality ( healthy lives) and in a healthy environment.

Planet

• Protect the planet from degradation, including through sustainable consumption and

production, sustainably managing its natural resources and taking urgent action on

climate change

Prosperity

• All human beings can enjoy prosperous and fulfilling lives and that economic, social

and technological progress occurs in harmony with nature.

Peace

• Foster peaceful, just and inclusive societies which are free from fear and violence.

Partnership

• A revitalised Global Partnership for Sustainable Development, based on a spirit of

strengthened global solidarity, focussed in particular on the needs of the poorest and

most vulnerable and with the participation of all countries, all stakeholders and all

people

The language of the SDGs

• Ending hunger and

poverty

• Promoting wellness ,

health for all

• Protecting the planet

from abuse

• Building safe prosperity

• Providing safe places to

live

• Fostering peace

• “The healing of the

nations”

• “Preferential Options

for the Poor”

• “Leaving no-one

behind”

Healing our planet, the healing of the

nations Preamble to the Sustainable Development Goals - to heal our planet - the healing of the nations

Revelation 22:2

• On either side of the river was the tree of life, bearing twelve kinds of fruit, yielding its fruit every month; and the leaves of the tree were for the healing of the nations.

Ezekiel 47:12

"By the river on its bank, on one side and on the other, will grow all kinds of trees for food Their leaves will not wither and their fruit will not fail. They will bear every month because their water flows from the sanctuary, and their fruit will be for food and their leaves for healing."

Leaves

• Extraordinary ecosystem

• Photosynthesis - ( sunlight, water and C02

coveted into food and oxygen)

• Cooling, medicine, buildings, plates and

utensils, dyes

• Papyrus

Palliative Care – contribution to the

SDGs.

“The quality signatures

of a nation – how it

deals with birth and

death”

Liz Grant

Living - © Jo

Spiller

Unforgettable journeys

Though we are all born

equal we are born into,

and we die in, very

unequal circumstances.

We cannot change the

inevitability of death but we

can begin to change these

unequal circumstances

Through the keyhole - © Jo Spiller

Universal Health Coverage – ambition

of every country • Everyone receives the health services they need without

suffering financial hardship. It includes the full spectrum of

essential, quality health services, from health promotion to

prevention, treatment, rehabilitation, and palliative care.

• Everyone accesses the services that address the most

important causes of disease and death, and ensures that

the quality of those services is good enough to improve

the health of the people who receive them.

• Protects people from the financial consequences of

paying for health services out of their own pockets

reducing the risk that people will be pushed into poverty

What UHC is not Things that are not included in the scope of UHC:

1. UHC does not mean free coverage for all possible health interventions, regardless of the cost

2. UHC is not just about health financing. It encompasses all components of the health system: health service delivery systems, the health workforce, health facilities and communications networks, health technologies, information systems, quality assurance mechanisms, and governance and legislation.

3. UHC is not only about ensuring a minimum package of health services, but also about ensuring a progressive expansion of coverage of health services and financial protection as more resources become available.

4. UHC is not only about individual treatment services, but also includes population-based services such as public health campaigns, adding fluoride to water, controlling mosquito breeding grounds, and so on.

5. UHC is comprised of much more than just health; taking steps towards UHC means steps towards equity, development priorities, and social inclusion and cohesion.

WHO FACT SHEET 2017 http://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)

How can palliative care exemplify what

UHC is? Palliative care is about being able to choose the best and right and most timely intervention,– good PC can prevent unnecessary, inappropriate and costly practice.

MMPCU has modelled practice which answers the following questions –

What do we need to do to speak together about the right time to provide care/ and the time not to provide costly ineffective care

Whose responsibility is it and how to we encourage joint responsibility to share the core objectives of holistic person centred care?

• “my heart has become less heavy, I feel at peace, my pain is less’

How can palliative care exemplify what

UHC is?

Palliative care impacts all components of the health system

Palliative care demonstrates what can happen when we recognise the vulnerability of “health” and the value of care for the dignity of life, not the cure of a disease.

“before I thought it (palliative care) was about giving up” (Nurse, Kenya)

“Now I have the heart of listening to the patients, talking, counselling and assessing them” (Nurse, Uganda)

Creates

new

norms

Global perspective; palliative care

• Lancet Commission report Oct 2017

„Alleviating the

access abyss in

palliative care and

pain relief-an

imperative of

universal health

coverage‟

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 of

care within Universal Health Care

(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” of care – caring

for people because our patients are

our brothers and sisters

Palliative care models holism -

• rationale for care of the whole

person, dealing with their physical,

spiritual, emotional and social

needs.

How can palliative care exemplify UHC?

PATIENTS Who receive care and who also give of themselves as they care for loved ones

• A PARADIGM that places all people regardless of age, disease, place at the centre of care

• POLICIES that support a vision of care for all at all ages

• A PROGRAMME and PLANS that capture the vision, and outline the way in hospitals, districts and ministry

• PRECEPTORSHIP - training pre service curricula and in service

• A referral PATHWAY to ensure consistency of care

• PROTOCOLS to ensure confidence to make right decisions at the right time

• PURPOSEFUL PRESCRIBING (forms, people and places)

• PROCUREMENT Systems – making drugs consistently available

• PERFORMACE Systems ( enabling tools to ensure quality and capture change)

• PARTNERSHIPS A network of support - a net that works

• PASTORAL care and support

• PRESENCE both a physical presence and being physically present

PEOPLE All who plan, deliver, oversee and participate in care

How to evidence the microcosm of the

health system that is PC

How can palliative care exemplify what UHC is?

Not about minimum package of health services, but about a progressive expansion of coverage of health services and financial protection –

embedded in Palliative Care is engagement – it‟s everyone‟s business, the work of all.

MMPCU’s link Health worker programme

PC teaches us holism – recognition that the professions engaged and the team of carers is ever widening,

Recognition that patients‟ worries are not just about physical illness but about life – “who will look after my shamba?”, “who will feed my children?” “ how can I cope in the face of war, destruction and hopelessness?”

UHC is comprised

of much more than

just health; taking

steps towards UHC

means steps

towards equity,

development

priorities, and

social inclusion and

cohesion

Not about can we afford to deliver PC but can we

afford not to.

Lack of Palliative Care often means:

• Losing land and savings

• Out of pocket expenditure with no incoming redress

• School dropout because no money for fees

• Girls taken out of school to be carers

“material wealth strongly predicts the wealth of offspring via intergenerational wealth transfer. Ultimately, when parents lose their wealth to medical costs, future generations are gravely affected” (1)

1.Anderson, R. E., & Grant, L. (2017). What is the value of palliative care provision in low-resource settings?. BMJ Global Health, 2(1), https://doi.org/10.1136/bmjgh-2016-000139

2.World Health Organization. Chronic disease and health promotion. http://www.who.int/chp/chronic_disease_report/part2_ch2/en/index5.html

“existing knowledge underestimates the

implications of chronic diseases for poverty

and the potential that chronic disease

prevention and health promotion have for

alleviating poverty in low and middle income

countries.” (2)

How can palliative care exemplify

what UHC is?

UHC not just individual treatment services, but

population-based services such as public health

campaigns –

This is our call to action: palliative care is a public health

emergency

Global Pathways to build momentum

in palliative care • Principles of co-creation – participation, shared ethos

and values, purpose

• Preparing the ground - 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 doing, why we

are here, where our world is going and what we are

moving towards.

Paradigm of

Palliative care Global and

national movement for palliative care National Architect

ure Service infrastru

cture family and

community -

People

You and Me

Building a Model – MMPCU, APCA and University of

Edinburgh leading the way.

Core component

s 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

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

Integration: lesson learned

• Capacity building

• Curriculum integration

• Leadership training

• Mentorship

• Research and

evidence base

Grant L et al Integrating palliative care

into national health systems in Africa: a

multi–country intervention study June

2017 Journal of Global Health

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

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

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

• focuses on health systems rather than specific diseases

• urges palliative care integration into health worker training and education at all levels

• advocates for universal coverage

• highlights training needs inc. primary care, oncology, paediatrics, geriatrics and internal medicine

• urges governments to

fund palliative care

WHA Resolution on Palliative Care 2014

Lancet Commission on Global Access to Palliative care

and Pain Relief 2018

• focuses on Serious Health related Suffering

• Delineates an essential package of palliative care services urges palliative care integration

• advocates for holistic access to pain relief – morphine within a UHC framework

The legacy: Going forward

• What we can do: tell the story through the experiences of people – incorporating the problems and the solutions into the story (with the evidence)

• Conviction of why it matters and why the status quo is no longer tenable once the story has been told