Worldwide Hospice Palliative Care Alliance (WHPCA) Executive Director, Dr Stephen Connor, visited Ethiopia recently to explore how to advance community palliative care drawing on a centuries-old cultural practice.
Ethiopia has a population of about 100 million, yet there is only one hospice, three oncologists, and one cancer centre. Assistance with funerals and burials is provided within the community through groups known as ‘iddir’s’. Iddir’s were formed centuries ago by community members to help families pay for burial expenses when someone died. Now they do much more, including financial support for the person through illness and until death.
Despite this regular experience supporting people dying in their communities, iddir members have had no formal training in palliative or personal care. The WHPCA visit aimed to establish whether they has a desire to learn more, and whether a partnership between iddir groups, the local Hospice Ethiopia, and the WHPCA would be feasible as a way to advance palliative care in the country.
Ethiopia was chosen as one of six focus countries, one in each WHO region, by the WHPCA based on input from the membership, to advance implementation of the WHA palliative care resolution.
Founded in 2003 and based in the capital, Addis Ababa, Hospice Ethiopia provides care to people with serious illness and their families, trains healthcare workers in palliative care and conducts advocacy to raise awareness of palliative care and to create an enabling environment for providing palliative care in Ethiopia.
At the time of the WHPCA visit, the hospice had a caseload of 50 home care patients. An additional 25 patients receive day care at the hospice for six hours every Tuesday.
Following training by Hospice Africa Uganda, and supported by government legislation, Hospice Ethiopia clinical officers can prescribe and deliver locally produced oral liquid morphine to patients for the relief of severe pain. This simple and cost effective practice means that patients’ pain can be adequately controlled and their quality of life improved.
There is good community support for Hospice Ethiopia, including from various religious groups. They have strong relations with the local government offices, and work closely with many of the iddir groups.
Dr Connor met with the iddir office nearest to Hospice Ethiopia to discuss the proposed project. This office has 86 active iddir’s, each currently working with around 200 families. Iddir’s are imbedded in the cultural fabric of the community and each iddir is highly respected. The iddir members are extremely motivated to increase their palliative care knowledge and skills so as to better serve their community.
Iddir is a deeply rooted cultural practice throughout Ethiopia, with an iddir group in every community. The aims of iddir groups are closely aligned with the goal of advancing palliative care in communities throughout Ethiopia.
While iddir’s provide a robust network for advancing palliative care at the community level, at the national level the Ethiopian Ministry of Health has responded positively to advocacy, creating a policy environment conducive to quality palliative care provision.
The government has just published national palliative care clinical guidelines, and palliative care is being included in the training curricula of healthcare workers.
Palliative care is also in the general plan for Ethiopia health reform and it is now expected that each hospital will establish it. Hospitals will be measured on whether they have complied with this requirement, so there are considerable requests coming from the regions for training in palliative care.
During the WHPCA visit, Dr Nicola Ayers, Palliative Care Advisor in the Clinical Services Directorate of the Ethiopian Federal Ministry of Health, was leading a regional training for 23 physicians, nurses and pharmacists from the regions.
This was a 30-hour basic course in palliative care with the expectation that the attendees would return and establish palliative care in their hospitals.
WHPCA, Hospice Ethiopia and iddir’s project
To address the need for palliative care training in Ethiopia, taking advantage of the strong government support and building upon the culturally embedded iddir practice, the WHPCA and Hospice Ethiopia have designed a project to support and amplify the existing work of the iddir groups. The project will create a model compassionate community home care service that is culturally based.
The project will take place over two years, and serve a total of 1,000 patients and their families. Through the project, Hospice Ethiopia’s daily case load will increase from 50 to 80 people, with services expanding to serve five of the 10 sub-cities in Addis Ababa. It will demonstrate how to expand partnership between hospice and iddir groups throughout the country.
The project will work with five iddir offices, providing training to 20 iddirs in each woerda (district), with a total of 100 iddir’s trained to provide palliative care in their communities.
Staff from three hospitals in Addis Ababa will be included in the training through the project: St Paul Hospital, Yekatit 12 hospital and Tikuranbsa Hospital.
Dr Connor said: “Providing culturally appropriate palliative care is essential if we are going to reach the 80% of people needing palliative care who live in low and middle income countries. Partnership between Hospice Ethiopia and the iddir groups is a nearly perfect example of how to do this effectively”
Dr Ayers said: “When looking at the future of palliative care in Ethiopia, it is essential that we all work together. There is an Ethiopian proverb that says: ‘when spiders unite they can capture the lion’. So if we continue to work and 'spin our webs' together we can provide palliative care coverage in Ethiopia.”