Integration of palliative care into South Africa’s health system: A before and after implementation study

Abstract

Background: Providing palliative care (PC) is an ethical obligation, and health systems must ensure access for all patients with life-limiting and life-threatening conditions. South Africa’s National Policy Framework and Strategy for Palliative Care mandates integration into public services.
Aim: To assess integration of PC services, previously neglected, before and 2 years after policy implementation.
Setting: South Africa’s Cape Metro District.
Methods: A cross-sectional descriptive study compared baseline (March 2019–June 2019) and follow-up (March 2021–June 2021) via desktop and document review. Fifteen documents and quantitative changes in deidentified morphine use, as a tracer for outpatient PC pain control, and International Classification of Diseases (ICD)-10 coding, as a proxy for PC service availability, were reviewed. Other key measures included financing (number of beds, funding per bed), planning and service delivery (care pathways, referral process).
Results: Palliative care was partially integrated into primary care. Indicators of policy adoption included an increased number of PC beds in intermediate care facilities, significant growth in healthcare professionals trained in PC and increased morphine usage in some sub-districts. However, integration remained uneven across the district.
Conclusion: Integrating PC into an already overburdened health system is challenging. Further integration of PC is needed, together with training tailored for diverse professionals. Effective practices in some subdistricts of the region, such as optimised morphine prescribing and streamlined referral pathways, could serve as models for subdistricts where integration is less advanced.
Contribution: The study documents positive changes following policy implementation and underscores the importance of strong project management and resource mobilisation for successful integration of complex services like PC.