Palliative care project
Report from the planning trip, Ilembula, Tanzania 28.2.-10.3.
Anna Numminen, MD
I attended to Palliative care project planning trip 28.2.-10.3. with Dr. Reino Pöyhiä. I refer to
Dr. Pöyhiä's report regarding more detailed daily schedule and more careful analysis about
strengths and weaknesses of the project. In summary, the Home Based Care and Palliative
Care (HBC&PC) has started in the years 2003-2010 step by step. It previously received funds
from Colorado Hospice/USAID (13 500 USD in around 2010-2011). The Palliative team that
has nine members it make outreach trips in 16 villages around Ilembula, some of the villages
being very far, up to 2 hours to reach by car.. The team visits each village every 4th month that
is three times in a year. The main "work force" are the so called (52) volunteers, which are
women that the village elders or the village council has assigned for the post. The women do
the work in their free time, sometimes they take a day off from work (usually in their farms)
to meet the patients. Every volunteer should have 10-15 patients. Now because of lack of the
resources they can have up to 50 patients. The volunteers meet the palliative team monthly
and they refer complicated cases for the team to handle and are always free to ask for advice.
Strenghts:
- Motivated core team and fairly motivated volunteers
- The work has been running with minimum economical support for long time -> this is
evidence of continuity
- Basic functions (visits etc) are running smoothly
Weaknesses & things to concentrate on:
"Project based work" -> integrated work that would benefit the healthcare system
- The project is unfortunately kind of example of "Project based development aid". It is not yet
very well integrated as a part of hospital's other departments etc. in general. Some of the
doctors and nurses do refer the patients to the palliative care team and ask for their help but
what I understood from the descriptions this is still more of an exception than usual practise.
An other example of this are very much separately functioning CTC (HIV/AIDS) clinic and
palliative care team clinic. The patients are receiving the HIV drugs from one place (CTC
clinic) and palliative treatment is not integrated as part of this clinic's work. In the worst case
the patient may first travel to receive his/her drugs from Ilembula hospital and the next day
the palliative team travels to his/her village to treat the opportunistic infection etc.
-> The project plan for coming years should cover careful analysis of how to integrate the
palliative work
1) more as part of other work in the hospital (wards, out-patient-clinic etc)
2) and CTC work. This would need more co-operation and better facilities. (Patient could visit
the palliative clinic at the same time as they go and receive the drugs)
In my opinion it is not only palliative team's responsibility to plan how they could better
integrate the palliative work to support other clinical work (or vice versa) but this would be
mainly the responsibility of the hospital administration also to plan and to facilitate the
integration and co-operation. With limited resources and time it is a challenge but the project
plan should recover this aspect.
Palliative care or primary healthcare?
Palliative team treat also lot of other than palliative patients. Local dispensaries in the villages
(which are on government responsibility) should treat "healthy people normal infections" and
those clinics should also be able to provide help for palliative patients. Co-operation with local
dispensaries should be developed and consider education on this level too. In the WHO goals
developing the health systems are on first priority so this project should also strongly target
on developing the palliative care inside the healthcare system at all levels. The people who are
registered as palliative patients are still living most of the time (4 months) with out palliative
team visits so their pain relief cannot only rely on local volunteers contacting the palliative
team if there are problems. The dispensaries should be better equipped also to provide help.
Forms
The government has provided new forms that palliative should fill. Filling those forms require
much effort especially from the volunteers. The forms are not very clear. Distracting for
example statistics and valuable information from those forms is not easy.
-> The project should help to develop easier report system (with possibility to gather
statistics) still supporting the government report system.
This especially was discussed with Dr. Pöyhiä and he had valuable ideas about this.
Facilities
The current facilities are too small. It is hard to keep reception on the small room the team
has now. Own small ward with 4-8 beds and shelves for patient files etc would be major
improvement for the work. It would also provide a place for education and make the work
more familiar and visible for the rest of the hospital staff. Most importantly the right people
would treat the palliative patients that are in need of hospitalization in the right place.
Lack of young, motivated people
The current status of the palliative team is challenging. The responsibility is in few hands and
the possibilities to develop the work are limited not only because of lack of education or
financial support but because of lack of young, motivated professionals with adequate skills
(with ICT systems for example).
Education
There has not been enough education. This shortage is in a way "easiest" to respond cause we
have a experienced palliative care professional. The challenge for us is to have better and
wider understanding about the whole situation of the healthcare in Tanzania and to put this
work in the right context and to get experience about the special problems of HIV/AIDS
patients that are few in Finland (the medical problems are still very much the same so this is
not an hindrance/obstacle). The responsibility for the admin of hospital and nurse school
would be to find time for the education and also motivates people the pass the education on.